Download Chapter 24 B - Shoulder - Louisiana Workforce Commission

Chapter 23. Upper and Lower Extremities Medical Treatment Guidelines
Subchapter B. Shoulder Injury Medical Treatment Guidelines
Editor’s Note: Form LWC-WC 1009. Disputed Claim for Medical Treatment has been moved to §2328 of this Part.
§2315. Introduction
A. This document has been prepared by the Louisiana Workforce Commission, Office of Workers’
Compensation and should be interpreted within the context of guidelines for physicians/providers treating
individuals qualifying under Louisiana’s Workers’ Compensation Act as injured workers with shoulder injuries.
These guidelines are enforceable under the Louisiana Workers Compensation Act. All medical care, services, and
treatment owed by the employer to the employee in accordance with the Louisiana Workers’ Compensation Act shall
mean care, services, and treatment in accordance with these guidelines. Medical Care, services, and treatment hat
varies from these guidelines shall also be due by the employer when it is demonstrated to the medical director of the
office by a preponderance of the scientific medical evidence, that a variance from these guidelines is reasonably
required to cure or relieve the injured worker from the effects of the injury or occupational disease given the
circumstances. Therefore, these guidelines are not relevant as evidence of a provider’s legal standard of professional
care. To properly utilize this document, the reader should not skip nor overlook any sections.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1820 (June 2011).
§2317. General Guideline Principles
A. The principles summarized in this section are key to the intended implementation of all Office of Workers'
Compensation guidelines and critical to the reader's application of the guidelines in this document.
1. Application of Guidelines. The OWCA provides procedures to implement medical treatment guidelines and
to foster communication to resolve disputes among the provider, payer, and patient through the Office of Workers
Compensation.
2. Education. Education of the patient and family, as well as the employer, insurer, policy makers and the
community should be the primary emphasis in the treatment of workers’ compensation injuries. Currently,
practitioners often think of education last, after medications, manual therapy, and surgery. Practitioners must develop
and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers, and
the community as a whole. An education-based paradigm should always start with inexpensive communication
providing reassuring information to the patient. More in-depth education currently exists within a treatment regime
employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is
complete without addressing issues of individual and/or group patient education as a means of facilitating selfmanagement of symptoms and prevention.
3. Treatment Parameter Duration. Time frames for specific interventions commence once treatments have
been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as
availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the time frames
discussed in this document. Such deviation shall be in accordance with La. R.S. 23:1203.1
4. Active Interventions. Emphasizing patient responsibility, such as therapeutic exercise and/or functional
treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive
interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant
attainment of objective functional gains.
5. Active Therapeutic Exercise Program. Exercise program goals should incorporate patient strength,
endurance, flexibility, coordination, and education. This includes functional application in vocational or community
settings.
6. Positive Patient Response. Positive results are defined primarily as functional gains that can be objectively
measured. Standard measurement tools, including outcome measures, should be used.
a. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion (ROM),
strength, and endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity
measures that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective
findings.
7. Re-Evaluation of Treatment Every Three to Four Weeks. If a given treatment or modality is not producing
positive results within three to four weeks, the treatment should be either modified or discontinued. Reconsideration
of diagnosis should also occur in the event of poor response to a seemingly rational intervention.
8. Surgical Interventions. Surgery should be contemplated within the context of expected improvement of
functional outcome and not purely for the purpose of pain relief. The concept of "cure” with respect to surgical
treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of
clinical findings, clinical course, and diagnostic tests. A comprehensive assimilation of these factors must lead to a
specific diagnosis with positive identification of pathologic conditions. The decision and recommendation for
operative treatment, and the appropriate informed consent should be made by the operating surgeon. Prior to surgical
intervention, the patient and treating physician should identify functional operative goals and the likelihood of
achieving improved ability to perform activities of daily living or work activities and the patient should agree to
comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should
understand the length of partial and full disability expected post-operatively.
9. Pharmacy-Louisiana Law and Regulation: All prescribing will be done in accordance with the laws of the
state of Louisiana as they pertain respectively to each individual licensee, including, but not limited to: Louisiana
State Board of Medical Examiners regulations governing medications used in the treatment of non-cancer-related
chronic or intractable pain; Louisiana Board of Pharmacy Prescription Monitoring Program; Louisiana Department
of Health and Hospitals licensing and certification standards for pain management clinics; other laws and regulations
affecting the prescribing and dispensing of medications in the state of Louisiana.
10. Six Month-Time Frame. The prognosis drops precipitously for returning an injured worker to work once
he/she has been temporarily totally disabled for more than six months. The emphasis within these guidelines is to
move patients along a continuum of care and return-to-work within a six-month time frame, whenever possible. It is
important to note that time frames may not be pertinent to injuries that do not involve work-time loss or are not
occupationally related.
11. Return To Work. Return to work is therapeutic, assuming the work is not likely to aggravate the basic
problem or increase long-term pain. The practitioner must provide specific written physical limitations. If a
practitioner releases a patient at a level of function lower than their previous job position, the practitioner must
provide physical limitations and abilities and job modifications. A patient should never be released to simply
“sedentary” or “light duty.” The following physical limitations should be considered and modified as recommended:
lifting, pushing, pulling, crouching, walking, using stairs, climbing ladders, bending at the waist, awkward and/or
sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive
motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is
not necessarily contraindicated. The practitioner should understand all of the physical demands of the patient’s job
position before returning the patient to full duty and should request clarification of the patient’s job duties.
Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational
medicine physician, occupational health nurse, physical therapist, occupational therapist, vocational rehabilitation
specialist, or an industrial hygienist.
12. Delayed Recovery. Strongly consider a psychological evaluation, if not previously provided, as well as
initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury. The OWCA recognizes that 3 to 10 percent of all industrially
injured patients will not recover within the timelines outlined in this document despite optimal care. Such
individuals may require treatments beyond the limits discussed within this document, but such treatment will require
clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by
further treatment and impact upon prognosis.
13. Guideline Recommendations and Inclusion of Medical Evidence. Guidelines are recommendations based
on available evidence and/or consensus recommendations. When possible, guideline recommendations will note the
level of evidence supporting the treatment recommendation. When interpreting medical evidence statements in the
guideline, the following apply to the strength of recommendation.
Strong
Moderate
Weak
Inconclusive
Level 1 Evidence
We Recommend
Level 2 and Level 3
We Suggest
Evidence
Level 4 Evidence
Treatment is an Option
Evidence is Either Insufficient of Conflicting
a. Consensus guidelines are generated by a professional organization that the guidelines are intended to
serve. A committee of specialists and experts are selected by the organization to create an unbiased, vetted
recommendation for the treatment of specific issues within the realm of their expertise. All recommendations in the
guideline are considered to represent reasonable care in appropriately selected cases, regardless of the level of
evidence or consensus statement attached to it. Those procedures considered inappropriate, unreasonable, or
unnecessary are designated in the guideline as “not recommended.”
B. The remainder of this document should be interpreted within the parameters of these guideline principles that
may lead to more optimal medical and functional outcomes for injured workers.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1821 (June 2011), amended by the Louisiana Workforce Commission, Office of Workers Compensation,
LR 40:1162 (June 2014).
§2319. Initial diagnostic procedures
A. The OWCA recommends the following diagnostic procedures be considered, at least initially, the
responsibility of the workers’ compensation carrier to ensure that an accurate diagnosis and treatment plan can be
established. Standard procedures that should be utilized when initially diagnosing a work-related shoulder complaint
are listed below.
1. History Taking and Physical Examination (Hx & PE) are generally accepted, well-established and widely
used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic
procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing
each other, the objective clinical findings should have preference. The medical records should reasonably document
the following:
a.
History of Present Injury
i.
Mechanism of injury. This includes details of symptom onset and progression, and documentation of
right or left dominance;
ii.
Relationship to work. This includes a statement of the probability that the illness or injury is work-
iii.
Prior occupational and non-occupational injuries to the same area including specific prior treatment;
related;
iv.
History of locking, clicking, weakness, acute or chronic swelling, crepitation, pain while lifting or
performing overhead work, dislocation or popping. Pain or catching with overhead motion may indicate a labral tear.
Night time pain can be associated with specific shoulder pathology. Anterior joint pain, such as that seen in throwing
athletes, may indicate glenohumeral instability. Pain radiating below the elbow, may indicate cervical disc problems
or proximal entrapment neuropathy.
v.
Ability to perform job duties and activities of daily living; and
vi.
Exacerbating and alleviating factors of the reported symptoms. The physician should explore and
report on non-work related as well as, work related activities.
b.
Past History
i.
Past medical history includes previous shoulder conditions, neoplasm, gout, arthritis, diabetes and
previous shoulder symptoms;
ii.
Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, and other
systemic diseases;
iii.
Smoking history; and
iv.
Vocational and recreational pursuits.
c. Physical Examination: Examination should include the elbow and neck. Both shoulders should be
examined to compare asymptomatic and symptomatic sides and identify individuals with non-pathological joint
laxity or degenerative rotator cuff pathology. Physical examinations should consist of accepted tests and exam
techniques applicable to the joint or area being examined, including:
i.
visual inspection;
ii.
palpation, including the acromio-clavicular (AC) joint, sternoclavicular joint, and the subacromial
bursa in the region of the acromiohumeral sulcus;
iii.
range-of-motion/quality of motion;
iv.
strength, shoulder girdle weakness may indicate musculoskeletal or neurogenic pathology;
v.
joint stability;
vi.
integrity of distal circulation and limited neurologic exam;
vii.
cervical spine evaluation; and
viii.
if applicable, full neurological exam including muscle atrophy and gait abnormality.
ix.
specific shoulder tests
(a). This section contains a description of common clinical shoulder tests. Generally, more than one test
is needed to make a diagnosis. Clinical judgment should be applied when considering which tests to perform, as it is
not necessary to perform all of the listed tests on every patient. The physical examination may be non-specific
secondary to multi-faceted pathology in many patients, and because some tests may be positive for more than one
condition. Given the multitude of tests available, the physician is encouraged to document the specific patient
response, rather than report that a test is 'positive.' The tests are listed for informational purposes, and are also
referenced in Specific Diagnostic, Testing and Treatment Procedures.
(i). Rotator cuff/Impingement tests/Signs - Most published clinical examination studies assess rotator
cuff pathology. There is some evidence that tests are reliable for ruling out diagnoses, but not necessarily defining
the pathology accurately. Some studies indicate that the Neer test, Hawkins test, Jobe test, crossed-arm adduction
test, impingement sign and arc of pain are approximately 80 percent sensitive for impingement or rotator cuff
pathology. The drop arm, Yergason’s, Speed, and passive external Rotation Tests are thought to have specificity of
60 percent or higher. (Questions remain about interrater reliability.)
[a].Weakness with abduction.
[b].Arc of pain – Pain with 60 to 120 degrees of abduction.
[c].Neer impingement sign – Examiner flexes arm anteriorly to reproduce impingement. Positive if
pain is reproduced.
[d].Neer impingement test – When the Neer impingement sign is positive, the subacromial bursa is
injected with local anesthetic. If, after 40 minutes, the patient has sufficient pain relief so that the examiner can
perform the Neer impingement sign without recreating the initial pain, the test suggests impingement.
[e].Hawkins - arm is abducted to 90 degrees, forward flexed by 90 degrees with elbow flexed.
Examiner internally rotates the humerus. Pain suggests impingement.
[f].Drop arm - Patient slowly lowers arm from full abduction. If the arm drops, or if the patient is
unable to maintain slow progress from approximately 90 degrees, the test suggests rotator cuff tear.
[g].Lift off - patient’s hand is placed against back of waist with 90 degrees flexion of elbow. The
patient is asked to lift the hand off of his back at waist level. If the hand drops to the initial position against the
back, this suggests subscapularis tear or weakness. Some patients may not be able to perform the initial hand
placement due to pain or limited range-of-motion.
[h].Subscapularis strength test - Patient places hand on mid-abdomen, and then applies pressure. If the
elbow moves posteriorly or the wrist flexes, the test suggests subscapularis weakness or tear.
[i].Empty Can test - Patient’s arm abducted to 60 to 90 degrees with 30 degrees forward flexion and
with forearm pronated. Thumbs are pointing toward the floor. Patient resists examiner’s downward pressure on the
elbow. Weakness of the affected side, compared to the opposite side, or pain in subacromial area suggests
supraspinatus tear, tendonitis or tendonosis.
[j].External rotation lag test - the patient’s arm is abducted to 20 degrees with elbow flexed at 90
degrees, and almost fully externally rotated. If the patient cannot maintain the arm in external rotation, this suggests
a supraspinatus and/or infraspinatus tear.
[k].External rotation weakness – Elbows are flexed with arms at side, and patient attempts to externally
rotate against resistance. Weakness suggests infraspinatus and teres minor pathology.
[l].Impingement sign – Patient extends shoulder, then abducts and reports any pain
(ii). Acromioclavicular Joint Tests
[a].Crossed arm adduction – Examiner adducts arm across the body as far as possible toward the
opposite shoulder. If patient reports pain in the AC joint, this suggests AC joint pathology. Examiner may measure
the distance between antecubital fossa and the opposite acromion of the opposite shoulder. If one shoulder
demonstrates increased distance compared to the other shoulder, this suggests a tight posterior capsule.
[b].Paxino's - The examiner’s thumb is placed under the posterolateral aspect of the acromion, with the
index and long fingers on the superior aspect of middle part of the clavicle. Examiner applies anterior superior
pressure to acromion with thumb, and pushes inferiorly on the middle of the clavicle with index and long fingers. If
the patient reports increased pain in the AC joint, the test suggests AC joint pathology.
(iii). Labral Tears
[a].Labral tears which may require treatment usually occur with concurrent bicipital tendon disorders
pathology and/or glenohumeral instability. Therefore, tests for labral pathology are included in these sections.
(iv). Bicipital Tendon Disorders
[a].Yergason’s Test - The patient has the elbow flexed to 90 degrees. The examiner faces the patient,
grasps the patient’s hand with one hand and palpates the bicipital groove with the other. The patient supinates the
forearm against resistance. If the patient complains of pain in the biceps tendon with resistance, it suggests a positive
finding.
[b].Ludington's - The patient’s hands are placed behind the head, with the shoulders in abduction and
external rotation. If biceps contraction recreates pain, the test suggests biceps tendon pathology.
[c].Speed Test - The patient’s shoulder is flexed to 90 degrees and supinated. The examiner provides
resistance to forward flexion. If pain is produced with resistance, the test suggests biceps tendon instability or
tendonitis.
[d].Biceps Load Test II - The patient is supine with the arm elevated to 120 degrees, externally rotated
to maximum point, with elbow in 90 degrees of flexion and the forearm supinated. The examiner sits adjacent to the
patient on the same side, and grasps the patient’s wrist and elbow. The patient flexes the elbow, while the examiner
resists. If the patient complains of pain with resistance to elbow flexion, or if the pain is increased with resisted
elbow flexion, this may suggest a biceps related SLAP lesion in young patients.
(v). Glenohumeral Instability/Labral Tears/SLAP Lesions. Many of the following tests are also used to
test for associated labral tears. The majority of the tests/signs should be performed on both shoulders for
comparison. Some individuals have increased laxity in all joints, and therefore, tests/signs which might indicate
instability in one individual may not be pathologic in individuals whose asymptomatic joint is equally lax.
[a].Sulcus sign – With the patient’s arm at the side,
the examiner pulls inferiorly and checks for
deepening of the sulcus, a large dimple on the lateral side of the shoulder. Deepening of the sulcus suggests
instability.
[b].Inferior instability – With patient’s arm abducted to 90 degrees, examiner pushes down directly on
mid-humerus. Patient may try to drop the arm to the side to avoid dislocation.
[c].Posterior instability – The patient’s arm is flexed to 90 degrees anteriorly and examiner applies
posterior force to the humerus. The examiner then checks for instability.
[d].Apprehension – Patient's shoulder is in 90 degrees of abduction and in external rotation. Examiner
continues to externally rotate and apply axial force to the humerus. If there is pain, or if patient asks to stop, the test
suggests anterior instability.
[e].Relocation – Examiner applies posterior force on humerus while externally rotating. This is
performed in conjunction with the apprehension test. If symptoms are reduced, the test suggests anterior instability.
[f]. Load and shift or anterior and posterior drawer – Patient is supine or seated with arm abducted
from shoulder from 20 to 90 degrees and elbow flexed. Humerus is loaded by examiner, then examiner attempts to
shift the humeral head anterior, posterior, or inferior. Both shoulders should be tested. Results are graded using:
[i].
Grade 0, little or no movement;
[ii]. Grade 1, humeral head glides beyond the glenoid labrum; and
[iii]. Grades 2 & 3 actual dislocation of the humeral head off the glenoid.
[g].Anterior slide or Kibler test – Patient places hands on hips with thumb directed posteriorly.
Examiner applies force superiorly and anteriorly on the humerus, while the patient resists. If a click or deep pain
results, test suggests labral tear.
[h].Active compression (O’Brien) test – The patient has the shoulder in 90 degrees flexion and 10 to 15
degrees adduction. The arm is internally rotated so the thumb is pointing downward. The patient elevates the arm
while the examiner resists. If the patient experiences deep anterior shoulder pain that is relieved when the same
process is repeated with external rotation of the arm, the test suggests labral tear or AC joint pathology.
[i]. Crank test – The patient is standing and has arm elevated to 160 degrees in the scapular plane.
The examiner loads the glenohumeral joint while the arm is passively rotated internally and externally. The test is
repeated in the supine position. Pain, clicking, popping, or other mechanical grinding suggests labral tear and
possible instability.
[j].Compression rotation test – The patient is supine with shoulder abducted at 90 degrees. The
examiner applies an axial load across the glenohumeral joint while simultaneously passively rotating the patient’s
arm in internal and external rotation. Pain, clicking, popping, or other mechanical grinding suggests a labral tear and
possible instability.
[k].Pain provocation or Mimori test – The patient is seated upright with the shoulder in 90 degrees
abduction. The examiner maximally pronates and supinates the forearm while maintaining the shoulder at 90
degrees abduction. A positive test is suggested when pain or pain severity, is greater with the forearm pronated.
(vi). Functional assessment. The provider should assess the patient’s functional skills initially and
periodically during treatment. The initial exam will form the baseline for the patient’s functional abilities postinjury. This assessment will help the physician and patient determine when progress is being made and whether
specific therapies are having a beneficial effect. A number of functional scales are available that have been validated
in clinical research settings. Many of these scales were developed to evaluate specific diagnoses and will not be
useful for all patients with shoulder pain. The following areas are examples of functional activities the provider may
assess:
[a].interference with sleep;
[b].difficulty getting dressed or combing or washing hair;
[c].ability to do the household shopping alone;
[d].ability to shower or bath and dry oneself using both hands;
[e].ability to carry a tray of food across a room with both hands;
[f].ability to hang up clothes in the closet;
[g].ability to reach high shelves with the affected shoulder;
[h].difficulty with any other activities including sports and work duties;
[i].concerns about putting on overhead clothing;
[j].concerns that a specific activity might cause the shoulder to “go out”;
[k].a detailed description of ability to perform job duties.
[l].any positive historical information should be validated by the provider’s physical exam.
2. Radiographic Imaging of the shoulder is a generally accepted, well-established and widely used diagnostic
procedure when specific indications based on history and/or physical examination are present. It should not be
routinely performed for most non-traumatic diagnoses. The mechanism of injury and specific indications for the
radiograph should be listed on the request form to aid the radiologist and x-ray technician. For additional specific
clinical indications, Specific Diagnosis, Testing and Treatment Procedures. Indications include:
a.
inability to actively move arm through range-of-motion;
b.
history of significant trauma, especially blunt trauma or fall from a height;
c.
history of dislocation;
d.
age over 55 years;
e. unexplained or persistent shoulder pain over two weeks. (Occult fractures, may not be visible on initial
x-ray. A follow-up radiograph and/or bone scan may be required to make the diagnosis);
f.
history or exam suggestive of intravenous drug abuse or osteomyelitis; and
g. pain with swelling and/or range-of-motion (ROM) limitation localizing to an area of prior fracture,
internal fixation, or joint prosthesis.
3. Laboratory tests are generally accepted, well-established and widely used procedures. They are, however,
rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia,
connective tissue disorder, or underlying arthritis or rheumatologic disorder based on history and/or physical
examination. Laboratory tests can provide useful diagnostic information. The OWCA recommends that lab
diagnostic procedures be initially considered the responsibility of the workers' compensation carrier to ensure that an
accurate diagnosis and treatment plan can be established. Tests include, but are not limited to:
a. Completed Blood Count (CBC) with differential can detect infection, blood dyscrasias, and medication
side effects;
b. Erythrocyte sedimentation rate, rheumatoid factor, antinuclear antigen (ANA), human leukocyte antigen
(HLA), and C-reactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue
disorder;
c. Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic
bone disease;
d. Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications
requiring monitoring; and
e. Analysis of joint aspiration for bacteria, white cell count, red cell count, fat globules, crystalline
birefringence and chemistry to evaluate joint effusion.
7.
Other Procedures
a. Joint Aspiration: is a generally accepted, well-established and widely used procedure when specifically
indicated and performed by individuals properly trained in these techniques. Especially, when history and/or
physical examination are of concern for a septic joint or bursitis. Aspiration of a large effusion can help to decrease
pain and speed functional recovery. Persistent or unexplained effusions may be examined for evidence of infection,
rheumatologic, or inflammatory processes. The presence of fat globules in the effusion strongly suggests occult
fracture.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1822 (June 2011).
§2321. Follow-Up diagnostic imaging and testing procedures
A. One diagnostic imaging procedure may provide the same or distinctive information as does another
procedure. Therefore, the prudent choice of a single diagnostic procedure, a complement of procedures or a
sequence of procedures will optimize diagnostic accuracy; maximize cost effectiveness (by avoiding redundancy),
and minimize potential adverse effects to patients.
B. All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various
diagnoses. None is specifically characteristic of a certain diagnosis. Clinical information obtained by history taking
and physical examination should form the basis for selecting an imaging procedure and interpreting its results.
C. When a diagnostic procedure, in conjunction with clinical information, can provide sufficient information to
establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure. At the same
time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding
procedures, in conjunction with clinical information, cannot provide an accurate diagnosis. Usually, preference of a
procedure over others depends upon availability, a patient’s tolerance, and/or the treating practitioner’s familiarity
with the procedure.
1. Imaging Studies are generally accepted, well-established and widely used diagnostic procedures. When
indicated, the following additional imaging studies can be utilized for further evaluation of the shoulder, based upon
the mechanism of injury, symptoms, and patient history. For specific clinical indications, refer to Specific Diagnosis,
Testing and Treatment Procedures. The studies below are listed by frequency of use, not importance. Diagnostic
imaging may be useful in resolving the diagnostic uncertainties that remain after the clinical examination. Even a
thorough history and physical examination may not define the shoulder pathology that produces the patient’s
symptoms. Therefore, additional investigations should be considered as an accepted part of the patient evaluation
when surgery is being considered or clarification of diagnosis is necessary to formulate a treatment plan.
a. X-ray is widely accepted and frequently the first imaging study performed. Three radiographically
distinguishable acromion types have been described: Type I (flat), Type II (curved), and Type III (hooked).
Historically, acromion type was correlated with incidence of rotator cuff pathologies and with outcome of
nonsurgical treatment of shoulder pain. However, there is considerable variation between observers regarding the
acromial types, both in interpreting plain x-rays and in classifying anatomical specimens. Acromial morphology
should not be used to assess the likelihood of rotator cuff pathology. Acromial morphology alone should not be
considered an indication for acromioplasty, as up to 40 percent of asymptomatic adults may have a Type II
acromion. Appropriate soft tissue imaging techniques such as sonography and MRI should be used to assess rotator
cuff or bursa status.
b. Diagnostic Sonography is an accepted technique for suspected full-thickness tears. A positive sonogram
has a high specificity of 96 percent and provides convincing confirmation of the diagnosis. Sensitivity is high, 87
percent, however, negative sonography does not rule out a full-thickness tear. For partial thickness tears, a positive
sonogram has high specificity, 94 percent, but is only moderately sensitive, 67 percent. A negative sonogram does
not exclude the diagnosis of a partial thickness tear. The performance of sonography is operator-dependent, and is
best when done by a specialist in musculoskeletal radiology. It is preferable to MRI when the patient is
claustrophobic or has inserted medical devices.
c. Magnetic Resonance Imaging (MRI) is generally accepted and widely used to provide a more definitive
visualization of soft tissue structures, including ligaments, tendons, joint capsule, and joint cartilage structures, than
x-ray or Computed Axial Tomography (CT) in the evaluation of traumatic or degenerative injuries. The addition of
intravenous or intra-articular contrast can enhance definition of selected pathologies. In general, the high field,
conventional, MRI provides better resolution than a low field scan. A lower field scan may be indicated when a
patient cannot fit into a high field scanner or is too claustrophobic despite sedation. Inadequate resolution on the first
scan may require a second MRI using a different technique. All questions in this regard should be discussed with the
MRI center and/or radiologist. MRI provides excellent soft tissue detail, but interpretation of the image is
problematic and depends on operator skill. A positive MRI has high specificity of 93 percent and provides
supporting evidence that a clinical suspicion of a full-thickness tear is correct. Sensitivity of MRI for full-thickness
tears is also high at 89 percent. However, it may not identify the pathology in some cases. For partial thickness
tears, sensitivity of MRI is below 50 percent but its specificity is high at 90 percent.
d. Computed Axial Tomography (CT): is generally accepted and provides excellent visualization of bone
and is used to further evaluate bony masses and suspected fractures not clearly identified on radiographic window
evaluation. Instrument scatter-reduction software provides better resolution when metallic artifact is of concern.
e. MR Arthrography (MRA): This accepted investigation uses the paramagnetic properties of gadolinium to
shorten T1 relaxation times and provide a more intense MRI signal. It can accurately demonstrate and rule out fullthickness tears as well as non-contrast MRI, but it is invasive and its place in the evaluation of rotator cuff pathology
has not been determined. In select populations of highly active athletes, it may uncover unsuspected labral pathology
such as SLAP lesions, but the arthroscopically normal labrum may produce an abnormal signal in half of MRA
studies. Its contribution to the diagnosis of SLAP lesions has not been determined. An MRA is not necessary if the
patient has already met indications for arthroscopy or surgery as outlined in Specific Diagnosis, Testing and
Treatment. However, an MRA may be ordered when the surgeon desires further information prior to surgery.
f. Venogram/Arteriogram is a generally accepted test is useful for investigation of vascular injuries or
disease, including deep-venous thrombosis. Potential complications may include pain, allergic reaction, and deepvein thrombosis.
g. Bone Scan (Radioisotope Bone Scanning): is generally accepted, well-established and widely used. Bone
scanning is more sensitive but less specific than MRI. 99MTechnecium diphosphonate uptake reflects osteoblastic
activity and may be useful in metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory
lesions, but cannot distinguish between these entities. Bone scanning is more sensitive but less specific than MRI. It
is useful for the investigation of trauma, infection, stress fracture, occult fracture, Complex Regional Pain
Syndrome, and suspected neoplastic conditions of the upper extremity.
h. Other Radioisotope Scanning Indium and gallium scans are generally accepted procedures usually to
help diagnose lesions seen on other diagnostic imaging studies. 67Gallium citrate scans are used to localize tumor,
infection, and abscesses. 111Indium-labeled leukocyte scanning is utilized for localization of infection or
inflammation.
i. Arthrograms are accepted; however, rarely used except for evaluation of patients with metal implants and
previous shoulder surgery.
j. If the patient has a positive ultrasound, MRI, or Arthrogramonly one of these tests are necessary to
diagnose a rotator cuff tear. Any additional tests must be for additional diagnosis.
3.
Other Tests. The following diagnostic procedures in this subsection are listed in alphabetical order.
a. Compartment Pressure Testing and Measurement Devices: such as pressure manometer, are generally
accepted and useful in the evaluation of patients who present uncommon but reported symptoms consistent with a
compartment syndrome.
b. Doppler Ultrasonography/Plethysmography: is useful in establishing the diagnosis of arterial and venous
disease in the upper extremity and should be considered prior to the more invasive venogram or arteriogram study.
c. Electrodiagnostic Testing: Electrodiagnostic tests include but are not limited to, Electromyography
(EMG), and Nerve Conduction Studies (NCS). These are generally accepted, well-established and widely used
diagnostic procedures. Electrodiagnostic studies may be useful in the evaluation of patients with suspected
involvement of the neuromuscular system, including radiculopathies, peripheral nerve entrapments, peripheral
neuropathies, disorders of the neuromuscular junction and primary muscle disease. EMGs should not be routinely
performed for shoulder injuries unless there are findings to suggest new diagnostic pathology (Refer to Brachial
Plexus). In general, these diagnostic procedures are complementary to imaging procedures such as CT, MRI, and/or
myelography or diagnostic injection procedures. Electrodiagnostic studies may provide useful, correlative
neuropathophysiological information that would not be obtainable from standard radiologic studies. Portable
Automated Electrodiagnostic Device (also known as Surface EMG) is not a substitute for conventional EMG/NCS
testing in clinical decision-making, and therefore, is not recommended.
d.
Personality/Psychological/Psychiatric/Psycho-social Evaluation: These are generally accepted and
well-established diagnostic procedures with selective use in the upper extremity population, but have more
widespread use in subacute and chronic upper extremity populations. Diagnostic testing procedures may be useful
for patients with symptoms of depression, delayed recovery, chronic pain, recurrent painful conditions, disability
problems, and for preoperative evaluation. Psychological/psychosocial and measures have been shown to have
predictive value for postoperative response, and therefore should be strongly considered for use pre-operatively
when the surgeon has concerns about the relationship between symptoms and findings, or when the surgeon is aware
of indications of psychological complication or risk factors for psychological complication (e.g. childhood
psychological trauma). Psychological testing should provide differentiation between pre-existing conditions versus
injury caused psychological conditions, including depression and posttraumatic stress disorder. Psychological testing
should incorporate measures that have been shown, empirically, to identify comorbidities or risk factors that are
linked to poor outcome or delayed recovery. Formal psychological or psychosocial evaluation should be performed
on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do
not correlate with objective signs and test results. In addition to the customary initial exam, the evaluation of the
injured worker should specifically address the following areas:
i.
employment history;
ii.
interpersonal relationships-both social and work;
iii.
patient activities;
iv.
current perception of the medical system;
v.
current perception/attitudes toward employer/job
vi.
results of current treatment
vii.
treatment
risk factors and psychological comorbidities that may influence outcome and that may require
viii.
disability.
childhood history, including history of childhood psychological trauma, abuse and family history of
(a). Personality/ psychological/ psychosocial evaluations consist of two components, clinical interview
and psychological testing. Results should help clinicians with a better understanding of the patient in a number of
ways. Thus the evaluation result will determine the need for further psychosocial interventions; and in those cases,
Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis should be determined and documented. The
evaluation should also include examination of both psychological comorbidities and psychological risk factors that
are empirically associated with poor outcome and/or delayed recovery. An individual with a Ph.D., Psy.D, or
psychiatric M.D./D.O. credentials should perform initial evaluations, which are generally completed within one to
two hours. A professional fluent in the primary language of the patient is preferred. When such a provider is not
available, services of a professional language interpreter should be provided.
(i). Frequency: one-time visit for the clinical interview. If psychometric testing is indicated as a part of
the initial evaluation, time for such testing should not exceed an additional two hours of professional time.
4. Special Tests are generally well-accepted tests and are performed as part of a skilled assessment of the
patient's capacity to return-to-work, his/her strength capacities, and physical work demand classifications and
tolerances. The procedures in this subsection are listed in alphabetical order.
a. Computer Enhanced Evaluations: may include isotonic, isometric, isokinetic and/or isoinertial
measurement of movement, range-of-motion (ROM), endurance or strength. Values obtained can include degrees of
motion, torque forces, pressures, or resistance. Indications include determining validity of effort, effectiveness of
treatment and demonstrated motivation. These evaluations should not be used alone to determine return to work
restrictions. The added value of computer enhanced evaluations is unclear. Targeted work tolerance screening or
gradual return to work is preferred.
i.
Frequency: One time for evaluation. Can monitor improvements in strength every three to four weeks
up to a total of six evaluations.
b. Functional Capacity Evaluation (FCE): is a comprehensive or modified evaluation of the various aspects
of function as they relate to the worker's ability to return-to-work. Areas such as endurance, lifting (dynamic and
static), postural tolerance, specific range of motion, coordination and strength, worker habits, employability, as well
as psychosocial aspects of competitive employment may be evaluated. Components of this evaluation may include:
musculoskeletal screen; cardiovascular profile/aerobic capacity; coordination; lift/carrying analysis; job-specific
activity tolerance; maximum voluntary effort; pain assessment/psychological screening; and non-material and
material handling activities. When an FCE is being used to determine return to a specific jobsite, the provider is
responsible for fully understanding the job duties. A jobsite evaluation is frequently necessary. FCEs cannot be
used in isolation to determine work restrictions. The authorized treating physician must interpret the FCE in light of
the individual patient's presentation and medical and personal perceptions. FCEs should not be used as the sole
criteria to diagnose malingering. Full FCEs are sometimes not necessary. If Partial FCEs are performed, it is
recognized that all parts of the FCE that are not performed are considered normal. In many cases, a work tolerance
screening will identify the ability to perform the necessary job tasks.
i.
Frequency: Can be used initially to determine baseline status and for case closure when patient is
unable to return to pre-injury position and further information is desired to determine permanent work restrictions.
Prior authorization is required for FCEs performed during treatment.
c. Jobsite Evaluation: is a comprehensive analysis of the physical, mental, and sensory components of a
specific job. These components may include, but are not limited to; postural tolerance (static and dynamic); aerobic
requirements; range of motion; torque/force; lifting/carrying; cognitive demands; social interactions; visual
perceptual; sensation; coordination; environmental requirements of a job; repetitiveness; and essential job functions.
Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation. A
jobsite evaluation may include observation and instruction of how work is done, what material changes (desk, chair)
should be made, and determination of readiness to return to work. Requests for a jobsite evaluation should describe
the expected goals for the evaluation. Goals may include, but are not limited to the following:
i.
To determine if there are potential contributing factors to the person’s condition and/or for the
physician to assess causality;
ii.
To make recommendations for, and to assess the potential for ergonomic changes;
iii.
To provide a detailed description of the physical and cognitive job requirements;
iv.
To assist the patient in their return to work by educating them on how they may be able to do their job
more safely in a bio-mechanically appropriate manner; and/or
v.
To give detailed work/activity restrictions.
(a). Frequency: One time with additional visits as needed for follow-up visits per jobsite.
d. Vocational Assessment: The vocational assessment should provide valuable guidance in the
determination of future rehabilitation program goals. It should clarify rehabilitation goals, which optimize both
patient motivation and utilization of rehabilitation resources. If prognosis for return to former occupation
idetermined to be poor, except in the most extenuating circumstances, vocational assessment should be implemented
within 3 to 12 months post-injury. Declaration of MMI should not be delayed solely due to lack of attainment of a
vocational assessment.
i.
Frequency: One time with additional visits as needed for follow-up
e. Work Tolerance Screening: is a determination of an individual's tolerance for performing a specific job
based on a job activity or task and may be used when a full Functional Capacity Evaluation is not indicated. The
screening is monitored by a therapist and may include a test or procedure to specifically identify and quantify workrelevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues affecting the
patient’s return-to-work potential.
i.
Frequency: One time for initial screen. May monitor improvements in strength every three to four
weeks up to a total of six visits.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1825 (June 2011).
§2323. Specific Diagnosis, Testing and Treatment
A. Acromioclavicular joint sprains/dislocations. An acute acromioclavicular (AC) joint injury is frequently
referred to as a shoulder separation. There are six classifications of AC joint separation, which are based upon the
extent of ligament damage and bony displacement:
1.
Description/Definition:
a.
Type I - Sprain of the AC ligament and capsule; x-ray usually normal.
b. Type II - Sprains consisting of a ruptured AC ligament and capsule with incomplete injury to the
coracoclavicular (CC) ligament, resulting in mild AC joint subluxation. X-ray shows clavicle slightly elevated.
c. Type III - Dislocation of the clavicle above the acromion with complete tear of the AC ligament and/or
CC ligaments; abnormal stress x-rays.
d. Type IV. - Dislocation consisting of a displaced clavicle that penetrates posteriorly through or into the
trapezius muscle. The sterno-clavicular joint may also be dislocated.
e. Type V - Dislocation consisting of complete separation of the AC and CC ligaments and dislocation of
the acromioclavicular joint with a large coracoclavicular interval.
f.
Type VI - Dislocation consisting of a displaced clavicle that penetrates inferior to the coracoid.
2. Type I-III are common, while Types IV-VI are not, and when found require surgical consultation. For AC
joint degeneration from repetitive motion that is found to be work-related, refer to Impingement Syndrome.
3. Occupational Relationship: Generally, workers sustain an AC joint injury when they fall landing on the
point of the shoulder, driving the acromion downward; or fall on an outstretched hand or elbow with an adducted
arm, creating a backward and outward force on the shoulder. It is important to rule out other sources of shoulder
pain from the acute injury, including rotator cuff tear, fracture, and nerve injury.
4.
Specific Physical Exam Findings may include the following:
a. At times, tenderness at the AC joint with contusions and/or abrasions at the joint area; and/or
prominence/asymmetry of the shoulder can be seen;
b. The patient usually demonstrates decreased shoulder motion, and with palpation, the distal end of the
clavicle is painful. There may be increased clavicular translation and cross-body adduction that causes exquisite pain
at the AC joint. Cross-body adduction with the arm elevated to 90 degrees can also cause posterior pain with a tight
posterior capsule, or lateral pain with impingement. Injection of local anesthetic in the AC joint should relieve pain
when performing this maneuver.
5.
Diagnostic Testing Procedures: Plain x-rays may include:
a.
AP view;
b. AP radiograph of the shoulder with the beam angled 10 degrees cephalad (Zanca view) and a beam
strength that is under-penetrating;
c.
Axillary lateral views; and
d.
Stress view; side-to-side comparison with 10 to 15 lb. of weight in each hand.
6.
Non-operative Treatment Procedures may include:
a. Procedures outlined in Section F. Immobilization in some cases (up to 6 weeks for Type I-III AC joint
separations). Treatments for Type III injuries are controversial and may range from a sling to surgery.
b. Medication, such as non-steroidal anti-inflammatories and analgesics would be indicated. Narcotics are
not normally indicated. Lidocaine patches may be used for pain relief. In chronic acromioclavicular joint pain, a
series of injections with or without cortisone may be performed up to three times per year. Benefits may be achieved
through therapeutic rehabilitation. It should emphasize a progressive increase in range-of-motion (ROM) without
exacerbation of the AC joint injury. Full recovery of AC joint dislocation may require up to twelve weeks. With
increasing motion and pain control, a strengthening program should be instituted. Refer to Therapeutic Procedures,
Non-operative.
c. Return to appropriate modified duty should begin within the first week. Refer to Return to Work. With
restoration of full-motion, return to full-duty should be anticipated within three months.
d.
Other therapies in Therapeutic Procedures, Non-operative, may be employed in individual cases.
7. Surgical Indications: Patients who have Type III AC joint dislocations will usually recover well without
surgical intervention. Surgical intervention may be considered when functional deficits interfere with activities of
daily living and/or job duties after three to four months of active patient participation in non-operative therapy. For
patients with particularly high physical demands on their shoulder, immediate orthopaedic consultation with surgical
intervention as early as two weeks from the date of injury may be considered. Prior to surgical intervention, the
patient and treating physician should identify functional operative goals and the likelihood of achieving improved
ability to perform activities of daily living or work activities. The patient should also agree to comply with the preand post-operative treatment plan and home exercise requirements and understand the length of partial and fulldisability expected post-operatively. With a Type IV-VI AC joint injury, an orthopedic surgical consultation is
recommended.
8.
Operative Procedures:
a. AC joint stabilization with or without distal clavicle resection. Distal clavicle resection may prevent
painful arthritis but can compromise post-operative AC joint stabilization.
9.
Post-operative Treatment:
a. An individualized rehabilitation program based upon communication between the surgeon and the
therapist using the treatments found in Therapeutic Procedures, Non-operative.
b. Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive
strengthening.
i.
Frequency: Three to five times per week for the first two weeks, three times per week for the following
two weeks, then one to two times per week.
ii.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
iii.
Maximum Duration: 12 weeks. Occasional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
c. Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
10. Adhesive Capsulitis/Frozen Shoulder Disorder
a. Description/Definition: Adhesive capsulitis of the shoulder, also known as frozen shoulder disorder, is a
soft tissue lesion of the glenohumeral joint resulting in global restrictions of passive and active ROM. Lack of
passive ROM can persist even with therapy, for an average of 30 months. The disorder progresses through stages,
specifically:
i.
Stage 1Consists of acute pain with some limitation in range-of-motion; generally lasting two to nine
months.
ii.
Stage 2Characterized by progressive stiffness, loss of passive range-of-motion, muscular atrophy,
and decreased pain; generally lasting an additional 3 to 12 months beyond Stage 1.
iii.
Stage 3Characterized by partial or complete resolution of symptoms and restoration of ROM and
strength; it usually takes an additional 5 to 26 months beyond Stage 2.
iv.
Patients will usually complain of pain in the sub-deltoid region, but occasionally over the long head of
the biceps or radiating down the lateral aspect of the arm to the forearm. Pain is often worse at night, with difficulty
sleeping on the involved side. Motion is restricted and painful.
v.
In Stages 2 and 3, patients may also experience peri-scapular and neck pain from compensatory
scapular thoracic motion.
vi.
Idiopathic adhesive capsulitis usually occurs spontaneously without any specific inciting injury. This
occurs most frequently in diabetic, middle aged patients. This type of adhesive capsulitis is likely to remit over time
and is usually not work related.
vii.
Capsulitis or stiffness may occur secondary to trauma or surgery from another condition. Therapy and
additional treatment recommendations for other specific diagnoses should be strictly followed to decrease the
occurrence of secondary restricted ROM.
b. Occupational Relationship: There should be some history of work related injury. Occupational adhesive
capsulitis may arise secondary to any chest or upper extremity trauma. Primary adhesive capsulitis is rarely
occupational in origin.
c. Specific Physical Exam Findings may include: Restricted active and passive glenohumeral ROM in
multiple planes is the primary physical finding. It may be useful for the examiner to inject the subacromial space
with lidocaine and then repeat ROM testing to rule out stiffness secondary to rotator cuff or bursal pathology. Lack
of improvement of ROM usually confirms the diagnosis. Postural changes and secondary trigger points along with
atrophy of the deltoid and supraspinatus muscles may be seen.
d.
i.
Diagnostic Testing Procedures:
Plain x-rays should be done to rule out concomitant pathology such as subluxation or tumor.
ii.
Other diagnostic testing may be indicated to rule out associated pathology. Refer to Follow-up
Diagnostic Procedures and to Specific Diagnosis, Testing, and Treatment. Dynamic sonography may be useful to
specifically identify the movements most affected and rule out other pathology.
iii.
Laboratory tests should be considered to rule out systemic diseases.
e. Non-operative Treatment Procedures: Address the goal to restore and maintain function and may include
the following:
i.
Therapeutic interventions are the mainstay of treatment. They should include ROM, active therapies,
and a home exercise program. Passive as well as active therapies may be used for control of pain and swelling.
Therapy should progress to strengthening and instruction in a home exercise program targeted to further improve
ROM and strength of the shoulder girdle musculature. There is some evidence that a home exercise program will
have similar results to fully-supervised physical therapy in non-workers compensation populations; however, to
facilitate return to work, supervised therapy is generally recommended for at least several sessions to assure proper
performance of home exercise and to evaluate continued progress. These sessions are in addition to any sessions
already performed for the original primary related diagnosis. Refer to Therapeutic Procedures, Non-operative for all
other therapies as well as a description of active and passive therapies.
(a). Time to Produce Effect: Four sessions.
(b). Frequency: Two times per week for the first two weeks and one time or less thereafter.
(c). Optimum Duration: 8 to 12 sessions.
(d). Maximum Duration: 20 sessions per year. Additional follow-up visits may be justified to reinforce
exercise patterns or to reach final functional goals if therapy to date has demonstrated objective functional gains.
ii.
Return to work duties with increased ROM as tolerated are also helpful to increase function. Refer to
Return to Work.
iii.
Medications, such as NSAIDS and analgesics, may be helpful. Narcotics are indicated for postmanipulation or post-operative cases. Judicious use of pain medications to optimize function may be indicated.
Refer to Medications.
iv.
Subacromial bursal and/or glenohumeral steroid injections can decrease inflammation and allow the
therapist to progress with functional exercise and ROM. There is strong evidence that intra-articular injection of a
corticosteroid produces pain relief and increases ROM in the short-term for individuals with restriction of both
active and passive ROM in more than one direction. There is good evidence that the addition of a physical therapy
or home exercise program is more effective than steroid injections alone. Injections under significant pressure
should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible
tendon breakdown, tendon degeneration, or rupture. Injections should be minimized for patients under 30 years of
age. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check
their blood glucose level at least daily for 2 weeks after injections.
(a). Time to Produce Effect: One injection.
(b). Maximum Duration: Three injections in one year at least four to eight weeks apart, when functional
benefits are demonstrated with each injection.
v.
There is no clear long-term benefit for suprascapular nerve blocks, however, blocks may be appropriate
for patients when pain is not well-controlled and injections improve function.
(a). Time to Produce Effect: One block should demonstrate increased ability to perform exercises and/or
range-of-motion.
(b). Maximum Duration: Three per year.
vi.
In cases that are refractory to conservative therapy lasting at least three to six months, and in whom
ROM remains significantly restricted (abduction usually less than 90 degrees), the following treatment may be
considered:
(a). Distension arthrography or “brisement” in which saline, an anesthetic and usually a steroid are
forcefully injected into the shoulder joint causing disruption of the capsule. There is good evidence that distension
arthrogram with steroid and saline improves function in patients with decreased passive ROM after three months of
treatment. Early therapy to maintain ROM, and restore strength and function should follow distension arthrography.
Return to work with restrictions should be expected within one week of the procedure; return to full-duty is expected
within four to six weeks.
(b). Dynamic splinting may be appropriate for rare cases when a functional ROM has not been achieved
with the treatment listed above.
vii.
There is no evidence that hyaluronate injections are superior to physical therapy in this condition and
are not recommended.
viii.
Other therapies in Therapeutic Procedures, Non-operative, may be employed in individual cases.
f. Surgical Indications: Surgery may be considered when functional deficits interfere with activities of daily
living and/or job duties after three to six months of active patient participation in non-operative therapy. For most
individuals this constitutes limitations in the range of 130 degrees elevation and 120 degrees abduction; with
significant functional limitations; however, individuals who must perform overhead work and lifting may require a
greater ROM. Prior to surgical intervention, the patient and treating physician should identify functional operative
goals and the likelihood of achieving improved ability to perform activities of daily living or work activities. The
patient should also agree to comply with the pre- and post-operative treatment plan and home exercise requirements.
The patient should understand the length of partial and full disability expected post-operatively.
g. Operative Procedures: Manipulation under anesthesia which may be done in combination with steroid
injection, distension arthrography, or arthroscopy. Contraindications to closed manipulation under anesthesia include
anti-coagulation or bleeding diatheses, significant osteopenia, or recent surgical repair of shoulder soft tissue,
fracture or neurological lesion. Complications may include humeral fracture, dislocation, cuff injuries, labral tears or
brachial plexus injury. Arthroscopic capsular release or open surgical release may be appropriate in rare cases with
failure of previous methods and when the patient has demonstrated ability to follow through with required physical
and occupational therapy. Other disorders, such as impingement syndrome, may also be treated at the same time.
Radiofrequency is not recommended due to reported complications from chondrolyis.
h. Post-operative Treatment. An individualized rehabilitation program based upon communication between
the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative. Therapy may
include the following:
i.
Early therapeutic rehabilitation interventions are recommended to maintain ROM and should progress
to strengthening exercises.
ii.
Frequency: Suggested frequency pattern is three to five times per week for the first two weeks, three
times per week for the following two weeks, then one to two times per week. The exact frequency per week will
depend on the severity.
iii.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
iv.
Maximum Duration: Up to 12 weeks. Additional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
v.
Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
vi.
Patient should be approaching MMI within 8 to 12 weeks post-operatively; however, co-existence of
other pathology should be taken into consideration.
B. Bicipital Tendon Disorders
1.
Description/Definition:
a. Disorders may include: primary bicipital tendonopathy, which is exceedingly rare; secondary bicipital
tendonopathy, which is generally associated with rotator cuff tendonitis or impingement syndrome (see appropriate
diagnosis subsections); subluxation of the biceps tendon, which occurs with dysfunction of the transverse intertubercular ligament and rotator cuff tears; and acute disruption of the tendon, which can result from an acute
distractive force or transection of the tendon from direct trauma.
b. Symptoms may include aching, burning and/or stabbing pain in the shoulder, usually involving the
anterior medial portion of the shoulder girdle. The symptoms are exacerbated with above-the-shoulder activities and
those specifically engaging the biceps (flexion at the shoulder, flexion at the elbow and supination of the forearm).
Relief occurs with rest. Patients may report nocturnal symptoms which interfere with sleep during the acute stages
of inflammation; pain and weakness in shoulder during activities; repeated snapping phenomenon with a subluxing
tendon; immediate sharp pain and tenderness along the course of the long head of the biceps following a sudden
trauma which would raise suspicions of acute disruption of the tendon; and/or with predominant pain at the shoulder
accompanied by referral patterns which may extend pain into the cervical or distal structures, including the arm,
elbow, forearm, and wrist.
2.
Occupational Relationship.
a. Bicipital tendon disorders may include symptoms of pain and/or achiness that occur after repetitive use
of the shoulder and/or blunt trauma to the shoulder. Secondary bicipital tendonitis may be associated with
prolonged above-the-shoulder activities, and/or repeated shoulder flexion, external rotation and abduction. Acute
trauma to the biceps tendon of the shoulder girdle may also give rise to occupational injury of the biceps tendon.
b. Occupational disorders of the biceps tendon may accompany scapulothoracic dyskinesis, rotator cuff
injury, AC joint separation, sub deltoid bursitis, shoulder instability or other shoulder pathology. Symptoms should
be exacerbated or provoked by work that activated the biceps muscle. Symptoms may be exacerbated by other
activities that are not necessarily work related and the physician should explore and report these areas.
3.
Specific Physical Exam Findings may include the following:
a. If continuity of the tendon has been lost (biceps tendon rupture), inspection of the shoulder would reveal
deformity (biceps bunching/Popeye deformity). It is important to differentiate between distal and proximal tendon
rupture, as distal biceps ruptures often require urgent intervention.
b.
Palpation demonstrates tenderness along the course of the bicipital tendon.
c.
Pain at end range of flexion and abduction as well as with biceps tendon activation.
d. Provocative testing may include the following (a detailed description of the signs and tests is located in
initial diagnostic procedures):
i.
Yergeson's sign.
ii.
Speed's Test.
iii.
Ludington's Test.
iv.
Diagnostic Testing Procedures:
(a). Plain x-rays include:
(i). Anterior/Posterior (AP) view. Elevation of the humeral head is indicative of a rotator cuff tear;
(ii). Lateral view in the plane of the scapula or an axillary view determines an anterior or posterior
dislocation or the presence of a defect in the humeral head (a Hill-Sachs lesion);
(iii). Axillary view is also useful to demonstrate arthritis and spurs on the anterior inferior acromion;
and
(iv). Outlet view determines if there is a downwardly tipped acromion.
(b). Adjunctive testing, such as sonography, or MRI should be considered when shoulder pain is
refractory to four to six weeks of non-operative conservative treatment and the diagnosis is not readily identified by
standard radiographic and clinical techniques.
4.
Non-Operative Treatment Procedures:
a. Benefit may be achieved through procedures outlined in Non-operative Treatment Procedures, such as
appropriate modalities, limited acute immobilization, exercise and evaluation of occupational workstation. Therapy
should emphasize progressive increase in ROM. With increasing motion and pain control, a strengthening program
should be instituted.
i.
Time to Produce Effect: Four sessions.
ii.
Frequency: Two times per week for the first two weeks and one time or less thereafter.
iii.
Optimum Duration: 8 to 12 sessions.
iv.
Maximum Duration: 20 sessions per year.
b. Medication, such as nonsteroidal anti-inflammatory and analgesics would be indicated. Narcotics are not
normally indicated.
c. Biceps tendon sheath or subacromial steroid injections may be therapeutic. Injections under significant
pressure should be avoided as the needle may be penetrating the tendon. Injection into the tendon can cause tendon
degeneration, tendon breakdown, or rupture. Caution should be used in patients with a clinical suspicion of a partial
tear. Injections should be minimized for patients under 30 years of age.
d. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to
check their blood glucose level at least daily for two weeks after injections.
i.
Time to Produce Effect: One injection should provide demonstratable functional benefit.
ii.
Maximum Duration: Three injections per year at the same site when functional benefits are
demonstrated with each injection.
e. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer
to Return to Work. By 8 to 11 weeks, with restoration of full-motion, return to full-duty should be anticipated.
f.
5.
Other therapies in Therapeutic Procedures, Non-operative, may be employed in individual cases.
Surgical Indications:
a.
Acute Distal Biceps Tendon Rupture: normally requires urgent surgical repair.
b. Acute Proximal Long Head Biceps Tendon Rupture: active patient participation in non-operative
treatment is often successful; however, operative intervention may be indicated for young patients, manual laborers
or others who require forceful supination regularly for their work.
c. Bicipital Tendonitis: Conservative care prior to potential surgery must address flexibility and strength
imbalances. Surgery may be considered when functional deficits interfere with activities of daily living and/or job
duties after 12 weeks of active patient participation in non-operative therapy.
d. Subluxing Bicipital Tendon: Most patients with this condition also have a subscapularis tear. Surgical
stabilization of the bicipital tendon is not commonly indicated. Good outcome may be achieved through successful
rehabilitation procedures. Surgery may be considered when functional deficits interfere with activities of daily living
and/or job duties after 12 weeks of active patient participation in non-operative therapy.
e. Prior to surgical intervention, the patient and treating physician should identify functional operative goals
and the likelihood of achieving improved ability to perform activities of daily living or work activities and the
patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The
patient should understand the length of partial and full disability expected post-operatively.
6.
Operative Procedures:
a.
Distal Biceps tendon repair.
b.
Repair of rotator cuff pulley lesion.
c. Proximal tenodesis or tenotomy: Impingement of the biceps tendon can cause continued irritation, and
pain preventing shoulder elevation. Tenodesis or tenotomy has been used for decreased elevation after therapy in
conjunction with a sub scapular repair or irreparable rotator cuff tear.
7.
Post-operative Treatment:
a. An individualized rehabilitation program based upon communication between the surgeon and the
therapist using the treatments found in Therapeutic Procedures, Non-operative. Therapy may include the following:
b. It is reasonable to restrict ROM for two months for tenodesis or distal biceps tendon repair. Early loading
of the tendon should be avoided. Surgical patients may not recover sufficiently to perform full activity for 3 to 12
months. Rehabilitation, lasting at least 6 to 12 weeks, is necessary to facilitate Maximum Medical Improvement
(MMI).
i.
Frequency: Three to five times per week for the first two weeks, three times per week for the following
two weeks, then one to two times per week.
ii.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
iii.
Maximum Duration: 12 weeks. Occasional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
c. Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
C. Brachial Plexus and Shoulder Peripheral Nerve Injuries. Injuries to the brachial plexus and nerves of the
shoulder girdle region may result in loss of motor and sensory function, pain, and instability of the shoulder. Signs
and symptoms vary with the degree and mechanism of injury. The two modes of injury are: acute direct or indirect
traumatic injuries to the shoulder region, and repetitive motion or overuse. Transient compression, stretch or traction
(neurapraxia) causes sensory and motor signs lasting days to weeks. Damage to the axon (axonotmesis) without
disruption of the nerve framework may cause similar symptoms. The recovery time is delayed and depends upon
axon re-growth distally from the site of injury. Laceration or disruption of the entire nerve with complete loss of
framework (neurotmesis) is the most severe form of nerve injury and will invariably require surgical intervention.
Return of function is dependent upon re-growth of the nerve distal to the injury site. Full return of motor function is
variable and may take up to 18 months or longer. Electromyography (EMG) is the most commonly used diagnostic
modality to analyze nerve injuries. Electrophysiologic studies, such as electromyography and nerve conduction
studies are generally accepted, well-established and widely used for localizing the source of neurological symptoms.
These studies should be utilized as an extension of the history and clinical examination and to assess or monitor
nerve recovery. Studies should be performed three to four weeks following injury or description of symptoms.
Studies performed early may be falsely negative and usually require repeat testing three to four weeks after the
original injury. Thus, early testing is not generally recommended. If the symptoms have been present for longer than
three to four weeks, studies may be performed immediately after the initial evaluation. Serial studies may be
indicated if initial studies are negative and may also be useful for gauging prognosis. Limb temperature should be
controlled at 30 to 40 degrees centigrade. A description of six common nerve injuries to the shoulder girdle and their
treatment follow.
1.
Brachial Plexus Injuries:
a.
Description/Definition:
i.
The Brachial Plexus is formed by the nerve roots of C5-C8 and T1. These nerve roots exit the cervical
spine and pass through the scalene musculature. After leaving the scalene musculature, at the level of the clavicle,
they form trunks, division and chords which ultimately form the peripheral nerves of the arm.
b. Occupational Relationship: Direct injury to brachial plexus results in widespread sensory and motor loss.
Direct trauma, subluxation to shoulder, clavicular fractures, shoulder depression, or head deviation away from the
arm may result in variable brachial plexus lesions. Weight-lifting and carrying heavy back packs have also been
associated with plexus injuries. Most injuries involve the upper and/or lower trunks. Upper trunk plexopathies may
accompany full-thickness rotator cuff tears. Isolated middle trunk involvement is rare. Infraclavicular brachial
plexus injuries have been reported due to hematoma formation secondary to an axillary block. If this occurs,
emergency evacuation of the hematoma may be indicated. Symptoms may appear hours-to-days after the Procedure.
Severe motor and sensory axonal loss is frequently seen on electrodiagnostic studies. It is important to differentiate
injuries to the brachial plexus from the acquired (non work-related) Parsonage-Turner Syndrome or neuralgic
amyotrophy occurring without a history of trauma. This idiopathic syndrome begins with severe pain in the shoulder
girdle and is accompanied by resistance to passive motion. As the pain decreases, severe, near total weakness of one
or more shoulder girdle muscles occurs. Almost total recovery can be expected but occurs over two to three years.
c.
i.
Specific Physical Exam Findings may include:
Evidence of trauma or deformity;
ii.
Identification of sensory loss and demonstration of weakness which relates to the severity and anatomy
of the injury to the brachial plexus; and/or
iii.
Pain with recreation of the motions related to the mechanism of injury.
iv.
Diagnostic Testing Procedures:
(a). EMG may show acute or chronic denervation of specific nerves. Nerve Conduction Studies
demonstrating a loss of amplitude of 50 percent compared to the normal side are considered abnormal. NCVs/EMGs
will be repeated at appropriate intervals to assess reinnervation.
(b). If studies do not localize and give sufficient information, then additional information may be
obtained from MRI and/or myelography. These studies are employed to differentiate root avulsion from severe
brachial plexus injuries. Occasionally MRI may reveal the presence of an unexpected mass lesion consistent with a
tumor.
v.
Non-operative Treatment Procedures:
(a). In closed injuries, observation is favored. Repeat electrophysiologic studies may be helpful to assess
or monitor recovery.
(b). Rehabilitation is based on procedures set forth Non-operative Treatment Procedures. However,
utilization of ultrasound, and cold and heat should be discussed with the primary care physician, since these
modalities may aggravate nerve injury.
(c). Medications such as analgesics, nonsteroidal anti-inflammatories, anti-depressants and anticonvulsants are indicated and narcotics may be indicated acutely. All medications should be prescribed as found in
Thoracic Outlet Syndrome Guidelines.
(d). Return to work with appropriate restrictions should be considered early in the course of treatment.
Refer to Return to Work.
vi.
Surgical Indications:
(a). In open injuries, acute exploration may be indicated if nerve discontinuity is visualized. Surgery may
be considered post-injury when functional deficits interfere with activities of daily living and/or job duties after
active participation in non-operative therapy.
(b). In closed injuries, if functional deficits continue to be documented after three to four months of
active patient participation in non-operative therapy, then exploration may be warranted and a surgical consultation
should be considered. Patients with progressive weakness or a loss of function post-injury should be referred for
surgical consultation immediately.
vii.
Operative Procedures.
(a). Exploration and Repair.
viii.
Post-operative Treatment.
(a). An individualized rehabilitation program based upon communication between the surgeon and the
therapist. Treatment may include the following:
(b). Early therapeutic rehabilitation interventions are recommended to maintain range-of-motion (ROM)
and progressive strengthening.
2. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three times
per week for the following two weeks, then one to two times per week. The exact frequency per week will depend
on the severity and level of the nerve injury.
3.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
4. Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
a. Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
b.
Axillary Nerve:
i.
Description/Definition: This nerve is derived from the fifth and sixth cervical roots and passes around
the shoulder, supplying motor branches to the teres minor and the three heads of the deltoid. The axillary nerve
provides sensation to the top of the shoulder at the level of the deltoid.
5. Occupational Relationship: Direct injury and penetrating wounds to the shoulder and upward pressure on
the axilla can cause injury to the axillary nerve. Blunt trauma to the anterolateral shoulder has also been reported.
Abnormalities of the nerve can be seen with fractures of the surgical neck of the humerus and dislocation of the
shoulder. Axillary nerve injury may also occur from shoulder surgery. Patients complain of reduced abduction of
overhead strength and/or numbness in the lateral arm. The quadrilateral space syndrome may cause pain in the
axillary nerve region with abduction, external rotation, and extension. The axillary nerve and the posterior
circumflex artery are in the space bound by the long head of the triceps, the teres minor, subscapularis, and
latissimus dorsi when the arm is abducted. This syndrome is most commonly reported in young males 20 to 40 years
of age and has been associated with overhead sports.
6.
Specific Physical Exam Findings may include:
a.
weakness and atrophy of the deltoid muscle and teres minor;
b.
strength is lost in abduction, flexion and extension of the shoulder; and/or
c.
sensory loss is reported over the upper arm.
7.
Diagnostic Testing Procedures.
a.
Plain x-rays.
b. EMG and Nerve Conduction Studies three weeks after the injury and repeated at appropriate intervals to
assess for reinnervation. Comparison of EMG and NCV findings with the opposite side is usually necessary to
diagnose the degree of injury.
c.
MRI may be done to rule out other pathology.
d. To confirm quadrilateral space syndrome, an MRI angiogram may be done to visualize the posterior
circumflex artery occlusion in abduction. However, occlusion is present in 80 percent of normals also. This study
should only be done after conservative therapy and if surgery is being contemplated.
8.
Non-Operative Treatment Procedures:
a. Rehabilitation is based on procedures set forth in Non-operative Treatment Procedures. However,
utilization of ultrasound, and cold and heat should be discussed with the primary care physician since these
modalities may aggravate the nerve injury. Shoulder range-of-motion should be emphasized. For quadrilateral space
syndrome, stretching of the posterior shoulder and teres minor is recommended.
b. Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants and anti-convulsants
are indicated. Narcotics may be indicated acutely. All medications should be prescribed as described in Thoracic
Outlet Syndrome Guidelines.
c. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer
to Return to Work.
9. Surgical Indications: Surgical procedures are usually not necessary, since most injuries to the axillary nerve
are due to stretch and/or traction and recover within three to six months. Even when deltoid weakness persists,
return to full activity can be expected. One may consider surgery when functional deficits interfere with activities of
daily living and/or job duties after three to four months of active patient participation in non-operative therapy and
with EMG/NCV documentation of ongoing denervation and loss of function. Lesions secondary to direct penetrating
trauma or previous surgery may require more immediate intervention. Surgery for quadrilateral space syndrome is
not usually necessary as at least 70 percent of patients recover with conservative treatment. Indications may include
six months of conservative treatment with persisting functional deficits, a positive arteriogram, and point tenderness
at the posterior quadrilateral space. Overall outcomes of surgery cannot be predicted, as only a small case series
have been reported.
10. Operative Procedures:
a.
Exploration and Repair.
11. Post-Operative Treatment: An individualized rehabilitation program based upon communication between
the surgeon and the therapist. Treatment may include the following: Early therapeutic rehabilitation interventions are
recommended to maintain range-of-motion ROM) and progressive strengthening.
a. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three
times per week for the following two weeks, then one to two times per week. The exact frequency per week will
depend on the severity and level of the nerve injury.
b.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
c. Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
d. Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
e.
Long Thoracic Nerve.
12. Description/Definition:
a. The long thoracic nerve is formed by the cervical fifth, sixth, and seventh roots; it crosses the border of
the first rib and descends along the posterior surface of the thoracic wall to the serratus anterior.
13. Occupational Relationship:
a. Injury can occur by direct trauma to the posterior triangle of the neck or trauma may be the result of
chronically repeated or forceful shoulder depression. Repeated forward, overhead motion of the arms with the head
tilted or rotated to the unaffected side, as well as, stretch or compression of the nerve with the arms abducted, can
lead to long thoracic nerve dysfunction. Occasionally, severe traction with the shoulder compressed and the head
tilted may be associated with long thoracic nerve pathology.
14. Specific Physical Exam Findings may include:
a. dull ache in the region of the shoulder exacerbated by tilting the head away from the effected side and
without sensory loss;
b.
scapular deformity and/or winging may be described by patient or family; and/or
c.
serratus anterior wasting; and
d. scapular winging at the inferior border that may be demonstrated by asking the patient to forward elevate
and lean on his arms, such as against a wall and/or the examiner resisting protraction. (Spinal accessory nerve
pathology also causes winging when the patient is abducting.)
15. Diagnostic Testing Procedures.
a.
Plain x-rays.
b. EMG and Nerve Conduction Studies three weeks after the injury and repeated at appropriate intervals to
assess for reinnervation. Comparison of EMG and NCV findings with the opposite side is usually necessary to
diagnose the degree of injury. Studies may also exclude more widespread brachial involvement.
c.
MRIs or CTs if there is a need to rule out other pathology.
16. Non-Operative Treatment Procedures.
a. Rehabilitation is based on procedures set forth in Non-operative Treatment Procedures. Utilization of
ultrasound, cold, and heat should be discussed with the Primary Care Physician since these modalities can aggravate
nerve injury. Strengthening of the scapular stabilizers should be stressed.
b.
Orthotics may be used to stabilize the scapula but long-term benefit is not established.
c. Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants and anti-convulsants
are indicated and narcotics may be indicated acutely. All medications should be prescribed as seen in Thoracic
Outlet Syndrome Guidelines.
d. Return to work with appropriate restrictions should be considered early in the course of treatment (Refer
to Return to Work). Heavy lifting and other activities that might stress the nerve should be avoided.
17. Surgical Indications. Laceration of the nerve and progressive loss of function are indications for prompt
surgical intervention. Surgery may be considered when functional deficits interfere with activities of daily living
and/or job duties after four to six months of active participation in non-operative therapy. Surgical consultation
should occur at three to four months post-injury for these patients. In most cases, function will recover with
conservative therapy in 6 to 12 months.
18. Operative Procedures:
a.
exploration and repair;
b.
muscle transfer;
c.
scapular fixation.
19. Post-Operative Treatment: An individualized rehabilitation program based upon communication between
the surgeon and the therapist. Treatment may include the following: Early therapeutic rehabilitation interventions are
recommended to maintain ROM with progressive strengthening focusing on the scapular stabilizers.
a. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three
times per week for the following two weeks, then one to two times per week. The exact frequency per week will
depend on the severity and level of the nerve injury.
b.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
c. Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
d. Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
e.
Musculocutaneous Nerve.
D. Description/Definition:The nerve is derived from the fifth and sixth cervical roots. It innervates the
coracobrachialis, biceps and brachioradialis muscles and also provides sensation to the lateral aspect of the forearm.
E. Occupational Relationship:Trauma (including surgery) or penetrating wound to the brachial plexus,
coracobrachialis, and shoulder often can cause nerve injury. Most commonly, a stretch/traction injury with the arm
in abduction and external rotation induces nerve dysfunction. Cases have been reported to be associated with
backpack use, pitching, heavy weight-lifting, mal-position during sleep or surgery, and sudden, forceful extension of
the elbow. Complaints may include pain from the axilla into the forearm, biceps weakness, or sensation changes to
the lateral forearm from the lateral antebrachial cutaneous nerve.
1.
Specific Physical Exam Findings may include:
a.
weakness and atrophy in the biceps and brachialis; and/or
b.
2.
sensory loss over the lateral aspect of the forearm; however, this is not always seen.
Diagnostic Testing Procedures.
a. EMG and Nerve Conduction Studies three weeks after the injury and repeated at appropriate intervals to
assess for reinnervation. Comparison of EMG and NCV findings with the opposite side is usually necessary to
diagnose the degree of injury.
3.
Non-operative Treatment Procedures.
a. Rehabilitation is based on procedures set forth in Non-operative Treatment Procedures. Utilization of
ultrasound, cold and heat should be discussed with the primary care physician, since these modalities can aggravate
nerve injury.
b. Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants and anti-convulsants
are indicated and narcotics may be indicated acutely. All medications should be prescribed as seen in Thoracic
Outlet Syndrome Guidelines.
c. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer
to Return to Work.
4. Surgical Indications: Laceration of the nerve and progressive loss of function are indications for prompt
surgical intervention. Surgery may be considered when functional deficits interfere with activities of daily living
and/or job duties after four to six months of active patient participation in non-operative therapy. Surgical
consultation should occur at three to four months post-injury for these patients. In most cases, function will recover
with conservative therapy in 6 to 12 months.
5.
Operative Procedures.
a.
Exploration and Repair.
6. Post-operative Treatment: An individualized rehabilitation program based upon communication between
the surgeon and the therapist. Treatment may include the following: Early therapeutic rehabilitation interventions are
recommended to maintain ROM with progressive strengthening.
a. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three
times per week for the following two weeks, then one to two times per week. The exact frequency per week will
depend on the severity and level of the nerve injury.
b.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
c. Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
d. Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
e.
Spinal Accessory Nerve:
i.
Description/Definition: Spinal Accessory Nerve is the eleventh cranial nerve innervating the ipsilateral
sternocleidomastoid and trapezius muscles which are extremely important for scapular control and ultimately
shoulder function.
ii.
Occupational Relationship: Direct trauma to the posterior neck, forceful compression of the shoulder
downward, and/or deviation of the head away from the traumatized shoulder can lead to injury to this nerve such as
from a fall or motor vehicle accident. Surgical resection of the posterior neck can disrupt the nerve. Patients
complain of inability to fully elevate or abduct above horizontal.
7.
Specific Physical Exam Findings may include:
a.
pain in the shoulder;
b.
asymmetrical neckline;
c.
scapular winging with the arms out to the side, abduction, or with external rotation;
d.
weakness or paralysis of the trapezius with weakness in forward flexion or abduction above 90 degrees;
e.
drooping of the shoulder.
and/or
8.
diagnostic Testing Procedures:
a. EMG and Nerve Conduction Studies three weeks after the injury and repeated at appropriate intervals to
assess for reinnervation. Comparison of EMG and NCV findings with the opposite side is usually necessary to
diagnose the degree of injury.
b.
Radiographic procedures may be necessary to exclude lesions at the base of the brain or upper cervical
spine.
9.
Non-operative Treatment Procedures.
a. Rehabilitation is based on procedures set forth in Non-Operative Treatment Procedures. Utilization of
ultrasound, cold and heat should be discussed with the Primary Care Physician, since these modalities can aggravate
nerve injury. Resistance exercises to strengthen muscles. Braces may be used but probably have no long-term value.
b. Occupational work station will usually need significant modification due to inability to work above 90
degrees flexion or abduction. Return to work with appropriate restrictions should be considered early in the course
of treatment. Refer to Return to Work.
c. Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants and anti-convulsants
are indicated and narcotics may be indicated acutely. All medications should be prescribed as seen in Thoracic
Outlet Syndrome Guidelines.
10. Surgical Indications: Laceration of the nerve and progressive loss of function are indications for prompt
surgical intervention. Surgery may be considered when functional deficits interfere with activities of daily living
and/or job duties after four to six months of active participation in non-operative therapy. Surgical consultation
should occur at three to four months post-injury for these patients. In most cases, function will recover with
conservative therapy in 6 to 12 months.
11 Operative Procedures.
a.
exploration and repair;
b.
tendon transfertrapezius, levator scapular, rhomboids;
c.
scapular fixation for cases with heavy work demands and failed previous procedures.
12. Post-operative Treatment: An individualized rehabilitation program based upon communication between
the surgeon and the therapist. Treatment may include the following:
a. Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive
strengthening focusing on scapula stabilizers.
i.
Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three
times per week for the following two weeks, then one to two times per week. The exact frequency per week will
depend on the severity and level of the nerve injury.
ii.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
iii.
Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce
exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
iv.
Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
vi.
Suprascapular Nerve.
(a). Description/Definition. This nerve is derived from the fifth and sixth cervical root, superior trunk of
the brachial plexus and it innervates the supraspinatus and infraspinatus muscles of the rotator cuff.
(b). Occupational Relationship. Supraclavicular trauma, stretch, and friction through the suprascapular
notch or against the transverse ligament at the notch, or a fall on an outstretched arms can cause injury to the nerve.
Repetitive use of the arm has been shown on occasion to cause traction to the nerve. Damage, may occur secondary
to a ganglion cyst which usually causes infraspinatus atrophy. Ganglion cysts may be associated with labral
pathology and/or rotator cuff tears. These are most commonly reported in athletes. Up to one third of volley ball
players in one study had asymptomatic infraspinatus atrophy secondary to nerve damage. Nerve damage may also
occur associated with a full rotator cuff tear. Since the clinical findings are similar for both diagnoses, clinicians
should always consider the possibility of nerve damage when atrophy accompanies a rotator cuff tear.
(c). Specific Physical Exam Findings may include:
(i). pain at the shoulder;
(ii). wasting at the supraspinatus and/or infraspinatus muscles with weakness of external rotation and
abduction with overhead activity; and/or
(iii). a positive Tinel's eliciting a provocative pain response.
(d). Diagnostic Testing Procedures:
(i). EMG and Nerve Conduction Studies three weeks after the injury and repeated at appropriate
intervals to assess for reinnervation. Comparison of EMG and NCV findings with the opposite side is usually
necessary to diagnose the degree of injury.
(ii). If one suspects a mass lesion at the suprascapular notch or related labral or cuff pathology then an
MRI or sonography may be indicated.
(iii). CT scan with attention to the suprascapular notch may be used to evaluate for boney impingement.
(e). Non-operative Treatment Procedures:
(i). Resolution of symptoms usually occurs within 6 to 12 months of diagnosis with non-operative
treatment in the absence of lesions such as a cyst.
(ii). Rehabilitation is based on procedures set forth in Non-operative Treatment Procedures. An
emphasis should be placed on posture; maintaining full shoulder motion; strengthening; and stretching the posterior
capsule. Utilization of ultrasound, cold and heat should be discussed with the primary care physician, since these
modalities can aggravate nerve injury.
(iii). Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants, and anticonvulsants are indicated and narcotics may be indicated acutely. All medications should be prescribed as seen in
Thoracic Outlet Syndrome Guidelines.
(iv). Return to work with appropriate restrictions should be considered early in the course of treatment
(Refer to Return to Work). Heavy lifting or activities that aggravate the condition should be avoided.
13. Surgical Indications: Surgical release is warranted depending upon the presence of a ganglion cyst, results
of the electrophysiologic studies, and/or absence of improvement with conservative management. In cases without
cysts or other operative diagnoses, non-operative treatment may be tried for three to six months due to the observed
recovery rate of cases with no treatment. Difficulty performing functional activities after active patient participation
should be the deciding factor. [General Principles]
14. Operative Treatment Procedures.
a.
secompression and/or excision of ganglion cyst; and/or labral repair.;
b.
surgical release at the suprascapular notch or spinoglenoid region;
15. Post-operative Treatment: An individualized rehabilitation program based upon communication between
the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative. Treatment may
include the following: Early therapeutic rehabilitation interventions are recommended to maintain ROM with
progressive strengthening.
a. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three
times per week for the following two weeks, then one to two times per week. The exact frequency per week will
depend on the severity and level of the nerve injury.
b.
Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
c. Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
d. Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
F.
Bursitis/Rotator Cuff Tendonopathy (Alternate Spelling "Tendinopathy") of the Shoulder
1.
Description/Definition.
a. Bursitis: Acute or chronic inflammation of the bursa (a potential fluid filled sac) that may be caused by
trauma, chronic overuse, inflammatory arthritis, and acute or chronic infection, and generally presents with localized
pain and tenderness of the shoulder.
b. Tendonopathy includes the terms tendonitis, an inflammation of the tendon and tendonosis, noninflammatory degenerative processes.
c. Rotator cuff tendonopathy may involve one or more of the four musculotendonous structures arising
from the scapula and inserting on the lesser or greater tuberosity of the humerus may be involved. These structures
include one internal rotator (subscapularis), and two external rotators (infraspinatus and teres minor), and the
supraspinatus which assists in abduction.
d. History may include nocturnal pain, pain with over-the-shoulder activities, feeling of shoulder weakness
and specific limitations of movement. Prior treatment for presenting complaint(s) and pertinent familial history
should be obtained.
2. Occupational Relationship: Onset of symptoms, date, mechanism of onset, and occupational history and
current job requirements should be correlated with the intensity, character, duration and frequency of associated pain
and discomfort. Tendonopathy may include symptoms of pain and/or achiness that occur after blunt trauma or
repetitive use of the shoulder. Bursitis is often a sequela of an occupational strain or tendonopathy in the absence of
other mitigating factors.
3.
Specific Physical Exam Findings may include:
a. Palpation elicits localized tenderness over the particular bursa or inflamed tendon with loss of motion
during activity;
b.
Painful arc may be seen between 40 and 120 degrees; and/or
c. Bursitis may be associated with other shoulder injury diagnoses such as impingement, rotator cuff
instability, tendonitis, etc.; refer to applicable diagnosis subsections for additional guidelines.
4.
Diagnostic Testing Procedures:
a.
5.
Plain x-rays include:
AP view. Elevation of the humeral head indicates rotator cuff tear;
6. Lateral view in the plane of the scapula or an axillary view determines if there is anterior or posterior
dislocation, or the presence of a defect in the humeral head (a Hill-Sachs lesion);
7.
Axillary view is also useful to demonstrate arthritis and spurs on the anterior inferior acromion;
8.
Outlet view determines if there is a downwardly tipped acromion.
a. Lab Tests. Laboratory tests may be used to rule out systemic illness or disease when proper clinical
presentation indicates the necessity for such testing. Testing may include sedimentation rate, rheumatoid profile,
complete blood count (CBC) with differential, and serum uric acid level. Routine screening for other medical
disorders may be necessary, as well as, bursal aspiration with fluid analysis.
b. The subacromial injection has generally been considered the gold standard for differentiating ROM loss
from impingement versus rotator cuff tears. Alleviation from pain may help to confirm the diagnosis. Patients with
impingement should recover normal strength after the injection, while those with rotator cuff tears usually do not
recover normal strength. However, manually tested elevation strength perceived as normal does not always rule out
rotator cuff tear and this may contribute to incorrect diagnoses with this technique. There is good evidence that
blinded subacromial blocks are not accurate. Up to a third of blinded injections may involve the cuff, and are likely
to cause pain. This may lead to an incorrect diagnosis. One study demonstrated that at least half of the positive
responders did so up to 40 minutes after the injection; therefore, a negative response should not be diagnosed until
40 minutes post injection. The inaccuracy of the injection and patient response in some cases may contribute to its
inability to completely predict the amount of recovery from subacromial decompression.
c.
If there is a concern regarding needle placement, sonography or fluoroscopy may be used.
d. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to
check their blood glucose level at least daily for two weeks after injections.
9.
Non-operative Treatment Procedures:
a. Therapeutic interventions are the mainstay of treatment. They should include ROM, active therapies, and
a home exercise program. Passive as well as active therapies may be used for control of pain and swelling. Therapy
should progress to strengthening and instruction in a home exercise program targeted to further improve ROM and
strength of shoulder girdle musculature. Refer to Therapeutic Procedures, Non-operative.
b. May return to work without overhead activities and lifting with involved arm. An evaluation of the
occupational work being performed and the work station may be necessary to institute ergonomic changes or
accommodations. Return to work with appropriate restrictions should be considered early in the course of treatment.
Refer to Return to Work.
c.
Medications such as oral nonsteroidal anti-inflammatory, oral steroids and analgesics.
d. Steroid injections may be therapeutic. Injections under significant pressure should be avoided as the
needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon
degeneration, or rupture. Injections should be minimized for patients under 30 years of age.
i.
Time to Produce Effect: One injection.
ii.
Maximum: three injections at the same site per year when functional benefits are demonstrated with
each injection.
iii.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded
to check their blood glucose level at least daily for two weeks after injections.
e.
Other therapies outlined in Therapeutic Procedures, Non-operative, may be employed in individual cases.
10. Operative Procedures: Are not commonly indicated for bursitis or tendonopathy. Refer to other related
diagnoses in Specific Diagnosis Testing and Treatment Procedures.
11. Calcifying Tendodnitis
a.
Description/Definition:
i.
Calcifying tendonitis is characterized by the deposition of hydroxyapatite (calcium phosphate) in any
tendon of the rotator cuff. The supraspinatus tendon is affected most frequently. It is a morphologic diagnosis which
may be asymptomatic or may produce pain. It may be present in a painful shoulder without being the cause of the
pain. Radiographically evident calcifications are present without producing symptoms in some adults (7.5 percent to
20 percent). The calcifying process occurs in two phases: the formative phase, in which calcium deposits coalesce in
the tendon matrix, and the resorptive phase, in which the calcium deposits are removed by phagocytic cells. The
resorptive phase is thought to be the painful phase of the disorder. The etiology is not known, but trauma is
considered unlikely to be causative. Pain may be accompanied by loss of ROM, a painful arc of motion, or by
impingement signs. Morphologic classification of calcium deposits is based on the homogeneity and borders of the
deposit on plain x-ray. (Gartner and Simons Classifications) Type I is homogenous with well-defined borders. Type
II is heterogeneous in structure with sharp outline or homogenous in structure with no defined border. Type III is
cloudy and transparent with no well-defined border. Type III frequently resolves without treatment. Generally, they
are not associated with rotator cuff tears. The size of the deposit has not been shown to be correlated with severity of
symptoms.
b. Occupational Relationship. Symptomatic calcifying tendonitis may occur after repetitive loading of the
shoulder with force, such as with shoveling, raking, pushing, pulling, lifting at/or above shoulder level, or after blunt
trauma to the shoulder.
c.
Specific Physical Exam Findings may include:
i.
pain with palpation to the shoulder with active or passive abduction and external rotation of the
shoulder (painful arc);
ii.
pain with specific activation of the involved muscles; and/or
iii.
pain with impingement signs;
iv.
severe pain on examination in some cases.
d.
i.
Diagnostic Testing Procedures:
plain x-ray films including AP lateral, axial, 30 degrees caudally angulated AP, Outlet view.
ii.
If shoulder pain is refractory to 4 to 6 weeks of non-operative care and other diagnoses are suspected,
adjunctive testing, such as MRI, sonography or arthrography, may be indicated.
e.
Non-operative Treatment Procedures
i.
Therapeutic rehabilitation interventions are the mainstay of treatment. They should include ROM,
active therapies, and a home exercise program. Passive as well as active therapies may be used for pain control,
including iontophoresis. Therapy should progress to strengthening and instruction in a home exercise programs
targeted to ongoing ROM and strengthening of shoulder girdle musculature. Refer to Therapeutic Procedures, Nonoperative for other therapies as well as a description of active and passive therapies.
ii.
Medications such as oral nonsteroidal anti-inflammatories, analgesics, and narcotics for significant
pain. Refer to Medications.
iii.
May return to work without overhead activities and lifting with involved arm. An evaluation of the
occupational work station may be necessary to institute ergonomic changes or accommodations. Return to work
with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.
iv.
Therapeutic ultrasound (Refer to Passive Therapy) may be used for tendonitis. There is some evidence
that ultrasound alleviates symptoms, improves function, and reduces calcium deposits better than sham ultrasound in
the short term. The advantage of ultrasound beyond six weeks is not certain.
v.
Ultrasound-guided needle lavage and aspiration requires a physician skilled in sonographic techniques
and is still considered investigational due to lack of randomized controlled trials. It is less costly and reportedly less
painful than extracorporeal shock wave therapy. It requires prior authorization but may be an appropriate therapy in
select patients who fail other conservative treatment.
vi.
Extracorporeal shock wave therapy has good evidence for improving pain and function with calcifying
tendonitis Type I or II when conservative treatment has not resulted in adequate functional improvement (See
ESWT). General anesthesia or conscious sedation is not required for this procedure. Patients should be cautioned
regarding the potential of avascular necrosis.
vii.
Steroid injections may be therapeutic. Injections under significant pressure should be avoided as the
needle may be penetrating the tendon and injection into the tendon can cause tendon degeneration, tendon
breakdown, or rupture. Injections should be minimized for patients under 30 years of age.
(a). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be
reminded to check their blood glucose level at least daily for two weeks after injections.
(i). Time to Produce Effect: One injection.
(ii). Maximum: Three injections at the same site per year when functional benefits are demonstrated
with each injection.
viii.
cases.
Other therapies outlined in Therapeutic Procedures, Non-operative, may be employed in individual
f. Surgical Indications. When functional deficits interfere with activities of daily living and/or job duties
after three to four months of active patient participation in non-operative therapy. The natural history of
calcifications includes resorption over time, with or without therapy. Prior to surgical intervention, the patient and
treating physician should identify functional operative goals and the likelihood of achieving improved ability to
perform activities of daily living or work activities. The patient should agree to comply with the pre- and postoperative treatment plan and home exercise requirements. The patient should understand the length of partial and
full disability expected post-operatively.
g. Operative Procedures: Either an arthroscopic or open procedure may be used. Careful lavage to remove
all calcium deposits from the surgical field is important. Full recovery may vary from three to six months.
h. Post-operative Treatment. Individualized rehabilitation programs are based upon communication
between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative.
Treatment may include the following:
i.
Sling, pillow sling, or abduction splint;
ii.
Gentle pendulum exercise, passive glenohumeral range-of-motion and posterior scapular stabilizing
training can be instituted;
iii.
Patients can judiciously return to activities as tolerated per physician recommendations. If there is a
significant tendon repair, progression will be delayed;
iv.
Progressive resistive exercise program beginning at two months with gradual returning to full activity
at 4 to 6 months; all active non-operative procedures listed in Non-operative Treatment Procedures should be
considered.
(a). Frequency: Three to five times per week for the first two weeks, three times per week for the
following two weeks, then one to two times per week.
(b). Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
(c). Maximum Duration: 12 weeks. Occasional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
v.
Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon. Depending upon the patient's functional
response and their job requirements, return to work with job modifications may be considered as early as one week
post-operatively. The employer must be able to fully accommodate restrictions of overhead activities or heavy
lifting. Physician/surgeon should be very specific regarding restrictions for overhead activities and heavy lifting.
Work restrictions should be evaluated every four to six weeks during post-operative recovery and rehabilitation, with
appropriate written communications to both the patient and the employer. Should progress plateau, the provider
should re-evaluate the patient's condition and make appropriate adjustments to the treatment plan.
12. Fractures. There are five common types of shoulder fractures; each type will be addressed separately and in
the order of most frequent occurrence.
a.
Clavicular Fracture:
i.
Occupational Relationship: Can result from direct blows or axial loads applied to the upper limb;
commonly associated injuries include rib fractures, long-bone fractures of the ipsilateral limb and scapulothoracic
dislocations.
ii.
Specific Physical Exam Findings may include:
(a). Pain along the clavicle;
(b). Abrasions on the chest wall, clavicle and shoulder;
(c). Deformities in the above regions; and/or
(d). Pain with palpation and motion at the shoulder joint area.
iii.
Diagnostic Testing Procedures: Clavicle x-rays. If they do not reveal sufficient information, then a 20
degree caudal-cranial AP view centered over both clavicles can be done.
iv.
Non-operative Treatment Procedures:
(a). Most are adequately managed by closed techniques and do not require surgery. After reduction, the
arm is immobilized in a sling or figure-8 bandage. Shoulder rehabilitation is begun with pendulum exercises 10 to
14 days after injury. Subsequently, with pain control, the therapy program can be progressed with therapeutic
approaches as indicated in Non-operative Treatment Procedures.
(b). Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated; narcotics
may be indicated acutely for fractures and should be prescribed as indicated in Medications.
(c). All patients with fractures, especially those over 50, should be encouraged to ingest at least 1200 mg
of Calcium and 800 IU of Vitamin D per day. There is some evidence that, for women in the older age group (58 to
88) with low hip bone density, greater callus forms for those who adhere to these recommendations than those who
do not. Although the clinical implications of this are not known, there is greater non-union in this age group and
thus, coverage for these medications during the fracture healing time period is recommended. At this time there is no
evidence that bisphosphonates increase acute fracture healing.
(d). All female patients over 65 should be referred for an osteoporosis evaluation. Patients who have
been on prednisone at a dose of 5 to 7.5 mg for more than three months should be evaluated for glucocorticoid
induced osteoporosis. An osteoporosis evaluation may be considered for males who: are over 70, are physically
inactive, have previous fragility fracture, have a BMI less than 20, or have been hypogonadal for five years.
Evaluation may also be considered for patients on medications that can cause bone loss, patients who have suffered
a fracture due to a low-impact fall or with minimum to no provocation, and women under 65 with one of the
following: menopause before 40, current smoker, or body mass index less than 20. Low body weight appears to be
the best predictor of osteoporosis in women younger that 65. In one adequate study, all patients aged 50 to 75
referred to an orthopaedic department for treatment of wrist, vertebral, proximal humerus, or hip fractures received
bone mass density testing. 97 percent of patients had either osteoporosis (45 percent) or osteopenia (42 percent).
Referral is important to prevent future factures in these groups. Long-term care for osteoporosis is not covered under
workers compensation even though it may be discovered due to an injury-related acute fracture.
(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and
provided with appropriate counseling.
(f). Return to work with appropriate restrictions should be considered early in the course of treatment.
Refer to Return to Work.
v.
Surgical Indications: Open fractures, vascular or neural injuries requiring repair, bilateral fractures,
ipsilateral scapular or glenoid neck fractures, scapulothoracic dislocations, flail chest and non-union (displacedclosed fractures that show no evidence of union after four to six months). A Type II fracture/dislocation at the AC
joint where the distal clavicular fragment remains with the acromion and the coracoid, and the large proximal
fragment is displaced upwards is another indication for surgery. Completely displaced midclavicular fractures may
be an indication for surgical repair. There is some evidence that plate fixation of completely displaced fractures
involving the middle third of the clavicle leads to slightly better shoulder function than immobilization without
surgical fixation and shorter healing time. Conservatively treated completely displaced fractures heal with mild
decreases in strength and good patient satisfaction in 70 percent or more of cases. However, initial surgical repair
may be considered for patients who desire excellent shoulder function for sport or job activities and/or those with
approximately two cm or greater shortening of the clavicle. Because smokers have a higher risk of non-union and
post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively.
vi.
Operative Procedures: Repair of fracture or associated distal clavicular resection using plates and
screws or an intramedullary device.
vii.
Post-operative Treatment: An individualized rehabilitation program based upon communication
between the surgeon and the therapist. This program would begin with two to three weeks of rest with a shoulder
immobilizer while encouraging isometric deltoid strengthening. Pendulum exercises with progression to assisted
forward flexion and external rotation would follow. Strengthening exercises should be started at 10 to 12 weeks as
indicated in Non-operative Treatment Procedures.
viii.
Bone-Growth Stimulators
(a). Electrical: Preclinical and experimental literature has shown a stimulatory effect of externally
applied electrical fields on the proliferation and calcification of osteoblasts and periosteal cells. Ensuing clinical
literature on electrical stimulation of bone fractures has principally focused on the spine and lower extremity.
Several techniques have been developed to deliver an electrical stimulus to a fracture or osteotomy site. Nonsurgical
techniques include Capacitive Coupling (CC), which places skin electrodes on opposite sides of the bone being
treated. Pulsed Electromagnetic Field (PEMF) uses a current-carrying coil which induces a secondary electrical field
in bone. High-quality literature of electrical bone growth stimulation are lacking for shoulder injuries. Literature is
conflicting in the use of electrical stimulation in other regions of the body. Due to a lack of supporting scientific
evidence, it requires prior authorization and may be only considered when conventional surgical management has
failed.
(b). Low-intensity Pulsed Ultrasound: There is some evidence that low-intensity pulsed ultrasound,
applied by the patient at home and administered as initial treatment of the fracture, reduces the time required for
cortical bridging in certain fractures of bones outside the shoulder joint. Shoulder fractures were not included in this
literature. Non-union and delayed unions were not included in these clinical trials. Possible indications for LowIntensity Pulsed Ultrasound are non-unions or fractures that are expected to require longer healing time. Prior
authorization is required.
b. Proximal Humeral Fractures: Fractures of the humeral head have been classically described using Neer
criteria; however, literature has shown a low level of observer agreement. These fractures are commonly referred to
as one, two, three or four part fractures based on the number of fracture fragments. Displaced fractures of the greater
tuberosity and impacted angulated fractures of the humeral head also have specific associated problems.
i.
Occupational Relationship: May be caused by a fall onto an abducted arm; high-energy (velocity or
crush) trauma with an abducted or non-abducted arm. Associated injuries are common, such as glenohumeral
dislocation; stretch injuries to the axillary, musculocutaneous, and radial nerves; and axillary artery injuries with
high-energy accident.
ii.
Specific Physical Exam Findings may include:
(a). pain in the upper arm;
(b). swelling and bruising in the upper arm, shoulder and chest wall;
(c). abrasions about the shoulder; and/or
(d). pain with any attempted passive or active shoulder motion.
iii.
Diagnostic Testing Procedures:
(a). X-ray trauma series (three views) are needed; AP view, axillary view and a lateral view in the plane
of the scapula. The latter two views are needed to determine if there is a glenohumeral dislocation. When an axillary
view cannot be obtained, a CT should be done to rule out posterior dislocation.
(b). Vascular studies are obtained emergently if the radial and brachial pulses are absent.
(c). Classification can be by the Neer Method, however, agreement between observers using this method
is poor. There are four fragments: the humeral shaft, humeral head, greater tuberosity, and the lesser tuberosity. The
fragments are not usually considered fragments unless they are separated by 1 cm or are angulated 45 degrees or
more.
iv.
Non-operative Treatment Procedures
(a). Non-displaced and minimally displaced fractures are generally treated conservatively with broad
arm sling or body swath. There is some evidence that simple non-displaced proximal humeral fractures recover
normal function more quickly when physical therapy is started one week after the fracture than when it is started
three weeks after the fracture. Immobilization without physical therapy for more than one week is not
recommended.
(b). Anterior or posterior dislocation associated with minimally displaced fractures can usually be
reduced by closed means, but a general anesthetic is needed. These are usually not performed in the emergency
room in order to avoid displacement of the fracture.
(c). Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated; narcotics
may be indicated acutely for fracture and should be prescribed as indicated in Medications.
(d). Immobilization may be provided with a sling, to support the elbow, or with an abduction
immobilizer if a non-impacted greater tuberosity fragment is present. Immobilization is usually continued for four to
ix weeks; however, the time will vary according to the type of fracture and surgeon’s discretion.
(e). Shoulder rehabilitation is begun with pendulum exercises 0 to 14 days after injury. Light, functional
exercises may be added at two to four weeks post-injury. Subsequently, with pain control, the therapy program can
be progressed with therapeutic approaches as described in Non-operative Treatment Procedures. Home exercises are
essential for recovery.
(i). Time to Produce Effect: Six sessions.
(ii). Optimum Duration: Nine sessions.
(iii). Maximum Duration: 12 to 24 sessions.
(f). Use of the injured arm at work is determined by the orthopaedist. The patient may, however, return
to work without use of the injured arm soon after the injury. Refer to Return to Work.
(g). Also refer to osteoporosis in this Clavicular Fracture.
(h). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and
provided with appropriate counseling.
v.
Surgical Indications:
(a). Greater tuberosity fractures with 5mm of displacement usually require surgical fixation. However,
rehabilitation may start as early as two to three days post-operatively.
(b). Two-part fractures are repaired according to the surgeon’s preference. Internal fixation may be
necessary to prevent varus or valgus angulation of the humerus; however, it is unclear whether this technique is
more successful than more conservative treatment particularly in patients over 70. Percutaneous techniques and
closed reduction have both been used.
(c). Three and four-part fractures frequently require operative treatment. Internal fixation is commonly
used. Hemiarthroplasty may be used in the elderly population or for severely comminuted fractures. Use of this
technique in the younger active patients frequently leads to the need for revision surgery and/or increased wear of
the glenoid cavity. For four-part fractures with a fractured greater tuberosity, reverse arthroplasties have also been
described, however; they should rarely be used since the long-term success of this prosthesis is currently unknown.
This procedure is described under Section G. Therapeutic Procedures, Operative Shoulder Replacement
(arthroplasty).
(i). Because smokers have a higher risk of non-union and post-operative costs, it is recommended that
carriers cover a smoking cessation program peri-operatively.
vi.
Operative Procedures: Percutaneous or internal fixation of the fracture or arthroplasty.
vii.
Post-operative Treatment
(a). An individualized rehabilitation program based upon communication between the surgeon and the
therapist using the treatment found in Section F.
(b). Schanz pins will require removal, frequently between Two to six weeks.
(c). One-time Extracorporeal Shock Wave Therapy (ESWT) has been purported to increase healing in
non-union fractures of long bones. None have been tested in prospective controlled studies. They are all considered
experimental and are not recommended at this time.
(d). Bone-Growth Stimulators. (Refer to Clavicular Fractures.)
(e). Hyperbaric oxygen therapy – there is no evidence to support long-term benefit of hyperbaric oxygen
therapy for non-union upper extremity fractures. It is not recommended.
(f). Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
c.
Humeral Shaft Fractures:
i.
Occupational Relationship: A direct blow can fracture the humeral shaft at the junction of its middle
and distal thirds. Twisting injuries to the arm will cause a spiral humeral shaft fracture. High energy (velocity or
crush) will cause a comminuted humeral shaft fracture.
ii.
Specific Physical Exam Findings may include:
(a). deformity of the arm;
(b). bruising and swelling; and/or
(c). possible sensory and/or motor dysfunction of the radial nerve.
iii.
Diagnostic Testing Procedures:
(a). plain x-rays including AP view and lateral of the entire humeral shaft.
(b). vascular studies if the radial pulse is absent.
(c). compartment pressure measurements if the surrounding muscles are swollen, tense and painful and
particularly if the fracture resulted from a crush injury.
iv.
Non-operative Treatment Procedures:
(a). Most isolated humeral shaft fractures can be managed non-operatively.
(b). Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated. Narcotics
may be indicated acutely for fracture and should be prescribed as indicated in Section F.6, Medications.
(c). A coaptation splint may be used.
(d). At two to three weeks after injury, a humeral fracture orthosis may be used to allow for full elbow
motion.
(e). Return to work with appropriate restrictions should be considered early in the course of treatment.
Refer to Return to Work.
(f). Other therapies outlined in Therapeutic Procedures, Non-operative, may be employed in individual
cases.
(g). Refer to comments related to osteoporosis in Clavicular Fracture.
(h). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and
provided with appropriate counseling.
v.
Surgical Indications:Indications for operative care would include:
(a). open fracture;
(b). associated forearm or elbow fracture (i.e., the floating elbow injury);
(c). burned upper extremity;
(d). associated paraplegia;
(e). multiple injuries (polytrauma);
(f). A radial nerve palsy which presented after closed reduction;
(g). pathologic fracture related to an occupational injury; and/or
(h). inability to perform basic activities of daily living while following conservative care.
(i). because smokers have a higher risk of non-union and post-operative costs, it is recommended that
carriers cover a smoking cessation program peri-operatively.
vi.
Operative Procedures
(a). Accepted methods of internal fixation of the fracture include:
(i). A broad plate and screws; and/or
(ii). Intramedullary rodding with or without cross-locking screws may be used but is associated with
increased shoulder pain;
(b). Human Bone Morphogenetic Protein (RhBMP). Use of this material for surgical repair of shoulder
fractures requires prior authorization. Refer to Operative Procedures, for further details.
vii.
Post-operative Treatment:An individualized rehabilitation program based upon communication
between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative.
Treatment may include the following:
(a). Following rigid internal fixation, therapy may be started to obtain passive and later active shoulder
motion using appropriate therapeutic approaches as indicated in Section F, Non-operative Treatment Procedures.
Active elbow and wrist motion may be started immediately. Early therapeutic rehabilitation interventions are
recommended to maintain range-of-motion (ROM) and progressive strengthening.
(i). Frequency: Three to five times per week for the first two weeks, three times per week for the
following two weeks, then to two times per week.
(ii). Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
(iii). Maximum Duration: 12 weeks. Additional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains or if a
nerve injury accompanies the fracture.
(b). Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
(c). Bone Growth Stimulation. (Refer to Clavicular Fractures.)
d.
Scapular Fractures:
i.
Occupational Relationship. These are the least common of the fractures about the shoulder and include
acromial, glenoid, glenoid neck and scapular body fractures. With the exception of anterior glenoid lip fractures
caused by an anterior shoulder dislocation, all other scapular fractures are due to a high-energy injury.
ii.
Specific Physical Findings may include:
(a). pain about the shoulder and thorax;
(b). bruising and abrasions;
(c). possibility of associated humeral or rib fractures; and/or
(d). vascular problems (pulse evaluation and Doppler examination).
iii.
Diagnostic Testing Procedures:
(a). Trauma x-ray series - AP view, axillary view, and a lateral view in the plane of the scapula.
(b). Arteriography if a vascular injury is suspected.
(c). Electromyographic exam if nerve injuries are noted.
iv.
Non-operative Treatment:
(a). Non-displaced acromial, coracoid, glenoid, glenoid neck and scapular body fractures may all be
treated with the use of a shoulder immobilizer.
(b). Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated. Narcotics
may be indicated acutely for fracture and should be prescribed as indicated in Medications.
(c). Pendulum exercises may be started within the first week.
(d). Progress to assisted range-of-motion exercises at three to four weeks using appropriate therapeutic
procedures as indicated in Section F, Non-operative Treatment Procedures.
(e). Return to work with appropriate restrictions should be considered early in the course of treatment.
Refer to Return to Work.
(f). Refer to comments related to osteoporosis in Clavicular Fracture.
(g). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and
provided with appropriate counseling.
v.
Surgical Indications
(a). displaced acromial fractures.
(b). displaced glenoid fractures.
(c). displaced scapular body fractures in some circumstances.
(d). displaced fractures of the scapular neck and the ipsilateral clavicle.
(e). because smokers have a higher risk of non-union and post-operative costs, it is recommended that
carriers cover a smoking cessation program peri-operatively.
vi.
Operative Treatment
(a). displaced acromial fractures are treated with internal fixation.
(b). displaced glenoid fractures greater than 5 mm should be fixed internally. Fractures with less
displacement may be treated surgically according to the surgeon’s discretion. Two and three dimensional CT scans
may be useful in planning the surgical approach.
(c). displaced scapular body fractures require internal fixation if the lateral or medial borders are
displaced to such a degree as to interfere with scapulothoracic motion.
(d). displaced fractures of the scapular neck and the ipsilateral clavicle require internal fixation of the
clavicle to reduce the scapular neck fracture.
vii.
Post-operative Treatment: An individualized rehabilitation program based upon communication
between the surgeon and the therapist using the appropriate therapeutic procedures as indicated in Section F, Nonoperative Treatment Procedures. Treatment may include the following:
(a). A shoulder immobilizer is utilized. Pendulum exercises initially begin at one week, and deltoid
isometric exercises are started early at four to six weeks, active ROM is usually commenced.
(b). Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive
strengthening.
(i). Frequency: Three to five times per week for the first two weeks, three times per week for the
following two weeks, then one to two times per week.
(ii). Optimum Duration: 8 to 10 weeks with progression to home exercise and/or pool therapy.
(iii). Maximum Duration: 12 to 14 weeks. Occasional follow-up visits may be justified to reinforce
exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
(c). Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
e.
Sternoclavicular Dislocation/Fracture
i.
Occupational Relationship: Sudden trauma to the shoulder/anterior chest wall. Anterior dislocations
of the sternoclavicular joint usually do not require active treatment; however, symptomatic posterior dislocations
will require reduction.
ii.
Specific Physical Findings may include:
(a). Dysphagia and shortness of breath which requires emergency reduction.
(b). Pain at the sternoclavicular area;
(c). Abrasions on the chest wall, clavicle and shoulder;
(d). Deformities in the above regions; and/or
(e). Pain with palpation and motion at the sternoclavicular joint area.
iii.
Diagnostic Testing Procedures:
(a). Plain x-rays of the sternoclavicular joint are routinely done. When indicated, comparative views of
the contralateral limb may be necessary.
(b). X-rays of other shoulder areas and chest may be done if clinically indicated.
(c). CT scan for classification of pathology.
(d). Vascular studies should be considered if the history and clinical examination indicate extensive
injury.
iv.
Non-operative Treatment Procedures:
(a). Symptomatic posterior dislocations should be reduced in the operating room under general
anesthesia.
(b). Immobilize with a sling for three to four weeks. Subsequently, further rehabilitation may be utilized
using procedures set forth in Non-operative Treatment Procedures.
(c). Medications, such as analgesics and nonsteroidal anti-inflammatories, would be indicated. Narcotics
may be indicated acutely for fracture and should be prescribed as indicated in Medications.
(d). Return to work with appropriate restrictions should be considered early in the course of treatment.
Refer to Return to Work.
(e). Refer to comments related to osteoporosis in Clavicular fracture.
(f). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and
provided with appropriate counseling.
v.
Surgical Indications:
(a). failure of closed reduction.
(b). because smokers have a higher risk of non-union and post-operative costs, it is recommended that
carriers cover a smoking cessation program peri-operatively.
vi.
Operative Procedures
(a). reduction with soft tissue reconstruction is preferred;
(b). internal fixation - significant complications can occur with use of pins due to migration into other
tissues.
vii.
Post-operative Treatment: An individualized rehabilitation program based upon communication
between the surgeon and the therapist. This program would begin with four to six weeks of rest with a shoulder
immobilizer, followed by therapeutic rehabilitation interventions.
(a). Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive
strengthening.
(i). Frequency: Three to five times per week for the first two weeks, three times per week for the
following two weeks, then one to two times per week.
(ii). Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.
(iii). Maximum Duration: 12 weeks. Occasional follow-up visits may be justified to reinforce exercise
patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
(b). Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
13. Impingement Syndrome
a. Description/Definition: A collection of symptoms, not a pathologic diagnosis. The symptoms result
from the encroachment of the acromion, coracoacromial ligament, coracoid process, and/or the AC joint of the
rotator cuff mechanism that passes beneath them as the shoulder is moved. The cuff mechanism is intimately related
to the coracoacromial arch. Separated only by the thin lubricating surfaces of the bursa, compression and friction
can be minimized by several factors, such as:
i.
shape of the coracoacromial arch that allows passage of the subjacent rotator cuff;
ii.
normal undersurface of the AC joint;
iii.
normal bursa;
iv.
normal capsular laxity; and
v.
coordinated scapulothoracic function.
b. The impingement syndrome may be associated with AC joint arthritis and both partial and full thickness
rotator cuff tears, as well as, adhesive capsulitis/frozen shoulder. Normal function of the rotator cuff mechanism and
biceps tendon assist to diminish impingement syndrome.
i.
History may include
(a). delayed presentation (since the syndrome is usually not an acute problem). Patients will access care
if their symptoms have not resolved with rest, time and "trying to work it out";
(b). complaints of functional losses due to pain, stiffness, weakness and catching when the arm is flexed
and internally rotated; and
(c). sleep complaints are common and pain is often felt down the lateral aspect of the upper arm near the
deltoid insertion or over the anterior proximal humerus.
(d). occupational Relationship: Repetitive overuse of the upper extremity, often seen with constant
overhead motion.
c. specific Physical Exam Findings may include: As with most shoulder diagnoses, the examiner should
not rely upon one set of physical exam findings alone due to the lack of specificity and sensitivity of most tests and
common overlap of diagnoses. Physical examination findings may include the following:
i.
Range-of-motion is limited particularly in internal rotation and in cross-body adduction, which may
reflect posterior capsular tightness. Forward flexion and elevation may also be limited.
ii.
Passive motion through the 60 to 90 degrees arc of flexion may be accompanied by pain and crepitus.
This is accentuated as the shoulder is moved in-and-out of internal rotation.
iii.
Active elevation of the shoulder is usually more uncomfortable than passive elevation.
iv.
Pain on maximum active forward flexion is frequently seen with impingement syndrome, but is not
specific for diagnosis.
v.
Strength testing may reveal weakness of flexion and external rotation in the scapular plane. This
weakness may be the result of disuse, tendon damage, or poor scapulothoracic mechanics.
vi.
Pain on resisted abduction or external rotation may also indicate that the integrity of the rotator cuff
tendons may be compromised, causing alteration of shoulder mechanics.
vii.
Weakness of the posterior scapular stabilizers causing alteration of shoulder mechanics can also
contribute to impingement syndrome.
viii.
If inspection of the shoulder reveals deltoid and rotator cuff atrophy other diagnoses should be
suspected such as cervical radiculopathy, axillary nerve pathology, or massive rotator cuff tears.
(a). Impingement syndromes commonly co-exist with other shoulder abnormalities such as rotator cuff
tears, AC joint arthritis, biceps tendon ruptures, calcifying tendonitis, bursitis, labral tears, and in older patients,
glenohumeral instability. This combination of pathology further complicates diagnostic decisions based mainly on
clinical findings. Physicians use a combination of test results with history and other findings to create a differential
diagnosis.
(b). Commonly used clinical tests include the following:
(i). Hawkins;
(ii). Neer;
(iii). Horizontal adduction;
(iv). Drop arm test;
(v). Yergason’s;
(vi). Speed test.
(c). Diagnostic Testing Procedures
(i). Plain x-rays include:
[a]. AP view is useful to evaluate for arthritis and elevation of the humeral head which are not
typically present in impingement syndrome.
[b]. Lateral view in the plane of the scapula or an axillary view can help to determine aspects of
instability which can give symptoms similar to impingement syndrome.
[c]. Axillary view is also useful to demonstrate glenohumeral arthritis and spurs on the anterior
inferior acromion.
[d]. Outlet view determines if there is a downward curved acromion. A downward curved acromion
does not necessarily establish the diagnosis of impingement syndrome and is not a sole indication for operative
treatment.
(ii). Adjunctive testing, sonography or MRI, may be considered when shoulder pain is refractory to
four to ix weeks of non-operative conservative treatment and the diagnosis is not readily identified by a good history
and clinical examination. (Refer to Follow-up Diagnostic Procedures.)
(iii). The subacromial injection has generally been considered the gold standard for differentiating
ROM loss from impingement versus rotator cuff tears. Alleviation from pain may help to confirm the diagnosis.
Patients with impingement should recover normal strength after the injection, while those with rotator cuff tears
usually do not recover normal strength. However, manually tested elevation strength perceived as normal does not
always rule out rotator cuff tear and this may contribute to incorrect diagnoses with this technique. There is good
evidence that blinded subacromial blocks are not accurate. Up to a third of blinded injections may involve the cuff,
and are likely to cause pain. This may lead to an incorrect diagnosis. One study demonstrated that at least half of
the positive responders did so up to 40 minutes after the injection. Therefore, a negative response should not be
diagnosed until 40 minutes post injection. The inaccuracy of the injection and patient response in some cases may
contribute to its inability to completely predict the amount of recovery from subacromial decompression.
(iv). If there is a concern regarding needle placement, sonography or fluoroscopy may be used.
(v). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be
reminded to check their blood glucose level at least daily for two weeks after injections.
(d). Non-operative Treatment Procedures
(i). An aggressive attempt should be made to define the contributing factors which are driving the
syndrome, such as shoulder stiffness, humeral head depressor weakness (rotator cuff fiber failure), posterior capsular
tightness and subacromial crowding, AC joint arthritis, muscle imbalance, and postural dysfunction.
(ii). Benefits may be achieved through therapeutic interventions. They should include ROM, active
therapies, and a home exercise program. Passive as well as active therapies may be used for control of pain and
swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further
improve ROM and strength of the shoulder girdle musculature. Refer to Therapeutic Procedures, Non-operative.
(iii). There is some evidence that manual therapy at a frequency of three times per week for four weeks,
increases function and decreases pain.
(iv). Patients may return to work without overhead activities and lifting with involved arm. An
evaluation of the jobsite may be necessary to institute ergonomic changes or accommodations. Return to work with
appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.
(v). Medications, such as nonsteroidal anti-inflammatories and analgesics, should be prescribed. Refer
to Medications.
(vi).
Subacromial space injection may be therapeutic. Injections under significant pressure
should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause tendon
degeneration, tendon breakdown, or rupture. Injections should be minimized for patients under 30 years of age.
[a]. Time to Produce Effect: One Injection.
[b]. Maximum: Three injections at the same site per year when functional benefits are demonstrated
with each injection. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be
reminded to check their blood glucose level at least daily for two weeks post injections.
(vii).
Other therapies in Therapeutic Procedures, Non-operative may be employed in individual
cases.
(e). Surgical Indications
(i). When functional deficits interfere with activities of daily living and/or job duties after three to six
months of active patient participation in non-operative therapy, surgery may restore functional anatomy and reduce
the potential for repeated impingement. Prior to surgical intervention, the patient and treating physician should
identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily
living or work activities and the patient should agree to comply with the pre- and post-operative treatment plan
including home exercise. The provider should be especially careful to make sure the patient understands the amount
of post-operative therapy required and the length of partial and full disability expected post-operatively.
(f). Operative Procedures
(i). Procedures might include partial coracoacromial ligament release, and an acromioplasty, as well
as, repair of associated pathology. An acromioplasty is not always necessary as an adjunct to rotator cuff repair.
There is some evidence that patients with a full-thickness rotator cuff tear and Type II acromions do not show
appreciable benefit from subacromial decompression.
(ii). Coplaning of the clavicle involves the removal of spurs from its inferior surface with the purpose
of increasing the space available for movement of the supraspinatus tendon. It is an acceptable procedure. Studies
are conflicting regarding possible pain sequelae at the acromioclavicular joint as a consequence of the procedure. In
cases with extensive rotator cuff repair, preservation of the coraco–acromial ligament is recommended to maintain
joint stability.
(g). Post-operative Treatment
(i). An individualized rehabilitation program based upon communication between the surgeon and the
therapist using the treatments found in Therapeutic Procedures, Non-operative. Treatment may include the
following:
(ii). sling, pillow sling, or abduction splint;
(iii). gentle pendulum exercise, passive glenohumeral range-of-motion, and posterior scapular
stabilizing training can be instituted;
(iv). patients can judiciously return to activities as tolerated per physician recommendations. If there is
a significant tendon repair, progression will be delayed;
(v). Progressive resistive exercise from six to eight weeks with gradual returning to full activity at four
to six months.
(vi). Return to work and restrictions after surgery may be made by an experienced primary
occupational medicine physician in consultation with the surgeon or by the surgeon. Depending upon the patient's
functional response and their job requirements, return to work with job modifications may be considered as early as
one week post-operatively, depending on job requirements. The employer must be able to fully accommodate
restrictions of overhead activities or heavy lifting. Work restrictions should be evaluated every four to six weeks
during post-operative recovery and rehabilitation with appropriate written communications to both the patient and
the employer. Should progress plateau, the provider should re-evaluate the patient's condition and make appropriate
adjustments to the treatment plan.
14. Rotator Cuff Tear
a. Description/Definition: Partial or full-thickness tears of the rotator cuff tendons, most often the
supraspinatus, can be caused by vascular, traumatic or degenerative factors or a combination. Further tear
classification includes: a small tear is less than 1cm; medium tear is 1 to 3cm; large tear is 3 to 5cm; and massive
tear is greater than 5cm, usually with retraction. Partial thickness cuff tears usually occur in age groups older than
30. Full-thickness tears can occur in younger age groups. Patient usually complains of pain along anterior, lateral
shoulder or posterior glenohumeral joint.
b. Occupational Relationship: May be caused by sudden trauma to the shoulder such as breaking a fall
using an overhead railing or an out-stretched arm; or chronic overuse with repetitive overhead motion or heavy
lifting; or moderate lifting in de-conditioned workers.
c.
i.
Specific Physical Exam Findings may include
partial Thickness Tear
(a). There may be pain at the end of range-of-motion (ROM) when full passive ROM for abduction,
elevation, external rotation and internal rotation are obtainable;
(b). Occasionally, there is a restriction of passive motion in one or more planes;
(c). Active ROM will be limited and painful for abduction and external rotation, as well as internal
rotation and forward flexion;
(d). A painful arc may be present with active elevation;
(e). Pain will be positive for resisted tests (abduction, flexion, external rotation, internal rotation,
abduction/internal rotation at 90 degrees, and abduction/external rotation at 45 degrees); and/or
(f). There may be positive impingement signs, refer to Impingement Syndrome.
ii.
Full-Thickness Tear
(a). Passive and resisted findings are similar to those for partial thickness tears with greater weakness of
abduction and external rotation;
(b). Active elevation may be severely limited with substitution of scapular rotation;
(c). Occasionally strength remains well preserved.
(d). Rotator cuff tears commonly co-exist with other shoulder abnormalities such as impingement, AC
joint arthritis, bicep tendon ruptures, calcifying tendonitis, and older patients with glenohumeral instability, bursitis,
and labral tears. This combination of pathology further complicates diagnostic decisions based mainly on the clinical
findings. Full-thickness tears are usually readily apparent from the drop arm test or weakness with elevation. For
other diagnoses, physicians should use a combination of test results with history and other findings to create a
differential diagnosis. The following tests may be used:
(i). hawkins;
(ii). drop arm;
(iii). lift off;
(iv). subscapularis strength test;
(v). empty can test;
(vi). external rotation lag test.
(e). Neurological lesions can occur with rotator cuff tears or may be missed as isolated lesions. When
muscle atrophy and weakness are present, the physician should consider neurologic lesions in the differential
diagnoses.
d.
Diagnostic Testing Procedures
i.
AP view is useful to evaluate for arthritis and elevation of the humeral head. Superior migration of the
humeral head is indicative of an extensive, and possibly irreparable, rotator cuff tear.
ii.
Lateral view in the plane of the scapula or an axillary view can help to determine aspects of instability
which can give symptoms similar to impingement syndrome.
iii.
acromion.
The axillary view is also useful to demonstrate glenohumeral arthritis and spurs on the anterior inferior
iv.
Outlet view determines if there is a downward curved acromion. A downward curved acromion does
not necessarily establish the diagnosis of impingement syndrome and is not a sole indication for operative treatment.
(a). Cases with the presence of significant weakness on elevation or rotation, a palpated defect at the
greater tuberosity or a traumatic history should have early MRI. Adjunctive testing such as sonography or MRI
should be considered for other shoulder cases refractory to four to six weeks of non-operative conservative
treatment. Sonography may be better at detecting partial thickness tears but is operator dependent. The sonogram is
very specific for rotator cuff tears but is not sensitive.
(b). Rotator cuff tears, both full-thickness and partial, appear to occur commonly in asymptomatic
individuals. Sonographic diagnostic criteria for rotator cuff tear may be met in approximately 39 percent of
asymptomatic persons, and MRI criteria for rotator cuff tear may occur in approximately 26 percent of
asymptomatic persons. There also appears to be a linear trend with age, such that more than half of asymptomatic
individuals over the age of 60 may demonstrate imaging changes consistent with rotator cuff tear, while a small
minority of patients younger than 40 demonstrate these changes. Correlation of radiological and clinical findings is
an important part of patient management.
e.
Non-operative Treatment Procedures
i.
Medications, such as nonsteroidal anti-inflammatories and analgesics, would be indicated. Acute
rotator cuff tear may indicate the need for limited narcotics use.
ii.
Relative rest initially and procedures outlined in Non-Operative Treatment Procedures. Therapeutic
rehabilitation interventions may include ROM and use a home exercise program and passive modalities for pain
control. Therapy should progress to strengthening and independent home exercise programs targeted to ongoing
ROM and strengthening of shoulder girdle musculature.
iii.
Return to work with appropriate restrictions should be considered early in the course of treatment.
Refer to Return to Work.
iv.
Other therapies outlined in Therapeutic Procedures, Non-operative, may be employed in individual
cases.
f.
Surgical Indications
i.
Goals of surgical intervention are to restore functional anatomy by re-establishing continuity of the
rotator cuff, addressing associated pathology and reducing the potential for repeated impingement.
ii.
Surgery may be indicated when functional deficits interfere with activities of daily living and/or job
duties after 6 to 12 weeks of active patient participation in non-operative therapy.
iii.
If no increase in function for a partial tear is observed after 6 to 12 weeks, a surgical consultation is
indicated. For full-thickness tears it is thought that early surgical intervention produces better surgical outcome due
to healthier tissues and often less limitation of movement prior to and after surgery. Patients may need pre-operative
therapy to increase ROM.
iv.
Full- thickness tears in individuals less than 60 should generally be repaired. Surgery for partial
thickness tears has variable results and debridement should be performed early in younger active patients. Many
patients with partial tears and good ROM and strength recover well without surgery. In patients over 65 the decision
to repair a full rotator cuff tear depends on the length of time since the injury, the amount of muscle or tendon that
has retracted, the level of fatty infiltration and the quality of the tendon. Procedures for these patients may include
biceps tendon repair and shaving of the humeral tuberosity. For patients with lack of active elevation above 90
degrees, arthroscopic biceps tenotomy and tenodesis may be effective in returning some elevation. Recurrence rate
may be up to 50 percent in older patients with multiple tendon full-thickness tears. Pseudo paralysis or severe
rotator cuff arthropathy are contraindications to the procedure.
v.
Literature suggests that the presence of three of the following factors may decrease the likelihood of a
successful repair: decreased passive ROM, superior migration of the humeral head, presence of atrophy, and/or
external rotation/abduction weakness strength. Presence of these conditions is not necessarily contraindications to
surgery, however, the patient should be made aware that the outcome may be less predictable.
vi.
Prior to surgical intervention, the patient and treating physician should identify functional operative
goals and the likelihood of achieving improved ability to perform activities of daily living or work activities and the
patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The
patient should understand the length of partial and full disability expected post-operatively.
vii.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged
to stop smoking and provided with appropriate counseling.
g.
Operative Procedures:
i.
Options would include arthroscopic or open debridement and/or repair. In some cases, partial
coracoacromial ligament release, and/or anterior acromioplasty.
ii.
An acromioplasty is not always necessary as an adjunct to rotator cuff repair. There is some evidence
that patients with a full-thickness rotator cuff tear and Type II acromions do not show appreciable benefit from
subacromial decompression.
iii.
Coplaning of the clavicle involves the removal of spurs from its inferior surface with the purpose of
increasing the space available for movement of the supraspinatus tendon. It is an acceptable procedure. Studies are
conflicting concerning the consequences of the procedure for the stability of the acromioclavicular joint.
iv.
Distal clavicular resection is not recommended for patients without AC joint pain.
v.
In cases with extensive rotator cuff tear, preservation of the coracoacromial ligament is recommended
to prevent instability.
vi.
Arthroscopic laser treatment is not recommended due to lack of evidence regarding outcomes.
h. Post-operative Treatment: Individualized rehabilitation program based upon communication between the
surgeon and the therapist. Treatment may include the following:
i.
Sling, pillow sling, or abduction splint. Sling protection for a period of two to eight weeks is usually
recommended after rotator cuff repair;
ii.
Gentle pendulum exercise, passive glenohumeral range-of-motion in flexion and external rotation to
prevent adhesions and maintain mobilization;
iii.
Isometrics and activity of daily living skills usually being six weeks post-operatively.
iv.
Active assisted range-of-motion exercises in supine with progression to sitting;
v.
discretion;
Light resistive exercise may begin at 6 to 12 weeks, depending on quality of tissue and surgeon’s
vi.
program;
Pool exercise initially under therapists or surgeon’s direction then progressed to independent pool
vii.
Progression to a home exercise program is essential;
viii.
Gradual resistive exercise from 3 to 12 months, with gradual return to full activity at 6 to 12 months;
ix.
Time frames for therapy (excluding pool therapy).
(a). Optimum: 24 to 36 sessions.
(b). Maximum: 48 sessions. If functional gains are being achieved additional visits may be authorized for
the patient to achieve their functional goal.
x.
Continuous passive motion is not generally recommended. It may be used if the patient has no home
assistance to regularly perform the passive movements required in the first six weeks and/or access to therapy is
limited.
xi.
Should progress plateau, the provider should re-evaluate the patient's condition and make appropriate
adjustments to the treatment plan. Refer to Therapeutic Procedures-Non-Operative for other therapies that may be
employed in individual cases.
xii.
Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon. Work restrictions should be evaluated every
four to six weeks during post-operative recovery and rehabilitation with appropriate written communications to both
the patient and employer. Return to full-duty too early in the course of tendon recovery increases the likelihood of
recurrent, symptomatic tears. Animal models estimate that the infraspinatus tendon regains only 30 percent of
strength at six weeks, 50 percent at three months, and 80 percent at six months. Therefore, return to any significant
lifting early in the course of recovery may result in failure of the surgery and/or recurrent tears.
15. Shoulder Instability/Glenohumeral Instability
a. Description/Definition: Subluxation (partial dislocation), or dislocation of the glenohumeral joint in
either an anterior, interior, posterior or a combination of positions.
i.
History may include:
(a). a slipping sensation in the arm;
(b). severe pain with inability to move the arm;
(c). abduction and external rotation producing a feeling that the shoulder might "come out"; or
(d). feeling of shoulder weakness.
b.
Occupational Relationship: Instability may be caused by any of the following:
i.
a direct traumatic blow to the shoulder;
ii.
a fall on an outstretched arm;
iii.
performing repetitive forceful overhead activities similar to pitching baseball;
iv.
a significant traction injury to the arm.
v.
In cases of subluxation symptoms may be exacerbated or provoked by work and initially alleviated
with a period of rest. Symptoms may also be exacerbated by other activities that are not necessarily work related
(e.g., driving a car or sports).
c.
Specific Physical Exam Findings may include
i.
Anterior dislocations may exhibit loss of normal shoulder contour; fullness in the axilla and pain over
the shoulder with any motion. The patient may hold the extremity in a static position;
ii.
Posterior dislocations usually occur with a direct fall on the shoulder or outstretched arm resulting in
posteriorly directed forces to the humeral head. Seizures or electrocution may also cause posterior dislocations.
Patients present with inability to externally rotate the shoulder;
iii.
Neurologic examination may reveal findings consistent with axillary nerve injuries, musculocutaneous
nerve injuries, generalized brachioplexopathies or other entrapment neuropathies;
iv.
Abduction and external rotation positioning classically produces apprehension in those who have
anterior instability. This finding may be present with other diagnoses. If apprehension is reproduced and then
relieved with positive posterior pressure after a positive first maneuver, this is considered a positive relocation test.
As with all shoulder diagnoses, a combination of physical findings and history should guide the provider in
determining the final diagnoses. Direct posterior stress may produce pain and apprehension in those with posterior
instability;
v.
The contralateral joint should always be examined. Patients who have laxity in multiple positions, who
have contralateral joint laxity or who have increased external rotation (90 degrees or more) with the arm at the side
are not likely to be surgical candidates and can be treated conservatively.
vi.
Other clinical findings (described in the Initial Diagnostic Procedures Section C):
(a). sulcus sign;
(b). inferior instability;
(c). posterior instability;
(d). apprehension, also known as crank, fulcrum or feagin;
(e). relocation;
(f). load and shift or anterior and posterior drawer.
d.
Diagnostic Testing Procedures
i.
Plain x-rays to rule out bony deficit on the glenoid, including AP, axillary view, lateral in the plane of
the scapula and possibly the West Point view. Axillary view to identify larger Hill-Sachs lesion of humeral head.
ii.
More difficult diagnostic cases with subtle history and physical findings suggesting instability, rotator
cuff or labral tear, may require a MRI or a CT arthrogram. This imaging may be useful to evaluate for labral
detachment and capsular stress injury or laxity after four to eight weeks of active patient involvement in therapy.
iii.
Suspected rotator cuff tear cases may require diagnostic arthroscopy.
e. Non-Operative Treatment Procedures: In subacute and/or chronic instabilities, age of onset of instability
is an important part of the history. Older patients are less likely to have recurrent dislocations unless they have
associated large rotator cuff tears. Therefore, the rotator cuff tear protocol should be followed if there is a suspicion
of this pathology. Associated axillary nerve injuries are more common in older patients. Patients less than 30 years
of age, especially males actively participating in sports, tend to have a higher recurrence rate, up to 75 percent in
some series. Surgery should be considered for these patients after the first dislocation. Avoid any aggressive
treatment in patients with history of voluntary subluxation or dislocation. These patients may need a psychiatric
evaluation. Patient may not return to work with overhead activity or lifting with involved arm until cleared by
physician for heavier activities.
i.
First-time dislocation
(a). Immobilization. There is no evidence that immobilization beyond splinting for comfort initially
affords any additional treatment advantage thus, it is not routinely required. Literature using MRI has shown that the
Bankart lesion is separated from the bone in internal rotation and apposed to the bone in external rotation. There is
some evidence that immobilization for three weeks with the shoulder in adduction and approximately 10 degrees of
external rotation reduces the risk of recurrent dislocation. Decisions concerning external rotation splinting versus
other options will depend on surgeon and patient preferences.
(b). Consider surgical intervention for young patients active in sports, or older patients with significant
rotator cuff tears. If additional pathology is present consult appropriate diagnostic categories.
(c). Medications such as analgesics and anti-inflammatories may be helpful. (Refer to medication
discussions in Medications.
(d). Other therapeutic procedures may include instruction in therapeutic exercise and proper work
techniques, evaluation of occupational work station and passive modalities for pain control. (Refer to Therapeutic
Procedures-Non operative, for specific time parameters.)
(e). Additional treatment may include, depending on level of improvement, manual therapy techniques,
work conditioning and other treatment found in section F.
(f). Patient may not return to work with overhead activity or lifting with involved arm until cleared by
physician for heavier activities. Return to work with appropriate restrictions should be considered early in the course
of treatment. Refer to Return to Work.
ii.
Acute or chronic dislocations: with a fracture contributing to instability;
(a). Practitioner should immobilize dislocations if in an acceptable position. Consultation should be
obtained as surgical repair may be necessary.
(b). Return-to-work will be directly related to the time it takes the fracture to heal.
iii.
Subacute and/or chronic instability:
(a). Chronic dislocations should first be treated similarly to acute dislocation. If continuing treatment is
unsuccessful, with findings of instability, operative repair should be considered.
f.
Surgical Indications
i.
Identify causative agent for the instability (i.e., labral detachment, bony lesion, large rotator cuff tear,
subscapularis tendon rupture, or multi-directional instability). There is strong evidence that initial operative repair in
young active patients results in fewer recurrent dislocations, thus, operative repair should be considered for these
patients. Those with Hill Sachs lesions, bony Bankart injuries, or significant glenoid bone loss have a worse
prognosis for recurrences.
ii.
Fractures not amenable to immobilization may also need operative management after the first
dislocation. Even with open repairs some decrease in function should be expected. Loss of external rotation is
common. In some cases the loss of motion may have an adverse effect on post-operative function. The desire for
surgery should carefully balance the desire to prevent recurrent dislocations and the need for ROM.
iii.
Older patients with documented large rotator cuff tears should also be considered for operative repair
after first time dislocations. Repair of the rotator cuff tear alone or in combination with stabilization should be
considered. Refer to the rotator cuff tear section.
iv.
In general, older patients without the above lesions will suffer few recurrences, and therefore, are
treated conservatively. Operative repair may be considered only after recurrent dislocations when functional deficits
interfere with activities of daily living and/or job duties and active patient participation in non-operative therapy has
occurred. Patients with multi-directional laxity and/or laxity in the contralateral shoulder are usually not good
candidates for operative repair.
g.
i.
Operative Procedures:
Bankart lesion repair; or
ii.
Capsular tightening. There is no evidence of benefit from thermal capsulorrhaphy and it is not
recommended;
iii.
Bony block transfer;
h.
Post-operative Treatment:
i.
An individualized rehabilitation program based upon communication between the surgeon and the
therapist. Depending upon the type of surgery, the patient will be immobilized for three to six weeks.
ii.
As soon as it is safe to proceed without damaging the repair, begin therapeutic exercise. Pool therapy
may be beneficial. Refer to Therapeutic Procedures, Non-operative for other therapies.)
iii.
During this period of time, the patient could resume working when the surgeon has cleared the patient
for specific activities and appropriate modifications can be made in the workplace. Return to work and restrictions
after surgery may be made by an experienced primary occupational medicine physician in consultation with the
surgeon or by the surgeon. Full ROM, lifting and pushing are prohibited usually for at least three months. Overhead
work may be restricted up to six months.
iv.
MMI can be expected three months after non-operative treatment and 6 to 12 months after operative
treatment. Further job assessment and adjusted work restrictions may be needed prior to the patients return to fullduty.
16. Superior Labrum Anterior and Posterior (Slap) Lesions
a. Description/Definition: Lesions of the superior aspect of the glenoid labrum that extend anteriorly and
posteriorly in relation to the biceps tendon insertion. There are several different types of SLAP lesions described.
i.
Type I is a fraying of the superior labral edge without detachment of the labrum from the glenoid rim.
ii.
Type II is a detachment of the biceps anchor from the glenoid. Three distinct Type II lesions have been
described as anterior only, posterior only, or combined anterior and posterior.
iii.
Type III is a bucket handle tear in the superior labrum only with biceps tendon and remainder of the
superior labrum having stable attachment.
iv.
Type IV is a bucket handle tear as in Type III, but with extension of the tear in to the biceps tendon.
Additional types of lesions have been described that include extensions of the above-described lesions or extensions
of Bankart lesions.
v.
History may include:
(a). Symptoms with overhead throwing motions;
(b). Dislocation, subluxation, or subjective sense of instability;
(c). Poorly localized shoulder pain that is exacerbated by overhead activities;
(d). Catching, locking, popping or snapping;
(e). Subtle instability.
b. Occupational Relationship: Common mechanisms of injury that are thought to contribute to SLAP
lesions include: compression injury such as fall on an outstretched arm with the shoulder in forward flexion and
abduction or direct blow to the glenohumeral joint; traction injury such as repetitive overhead throwing, attempting
to break a fall from a height, and sudden pull when losing hold of a heavy object; driver of an automobile who is
rear ended; repetitive overhead motions with force such as pitching; or a fall on adducted arm with upward force
directed on elbow. In some cases no mechanism of injury can be identified.
c. Specific Physical Exam Findings: The physical examination is often nonspecific secondary to other
associated intra-articular abnormalities. No one test or combination of tests has been shown to have an acceptable
sensitivity and specificity or positive predictive values for diagnosing SLAP lesion. Sensitivity and specificity are
relatively low for individual tests and combinations. Overall physical examination tests for SLAP lesions may be
used to strengthen a diagnosis of SLAP lesion, but the decision to proceed to operative management should not be
based on physical examination alone. Refer to Initial Diagnostic Procedures for specific descriptions of these signs
and tests.
i.
Speed Test.
ii.
Yergason’s Test.
iii.
Active Compression (O’Brien) Test.
iv.
Jobe Relocation Test.
v.
Crank Test.
vi.
Anterior Apprehension Maneuver.
vii.
Tenderness at the bicipital groove.
viii.
Anterior Slide (Kibler) Test.
ix.
Compression Rotation Test.
x.
Pain Provocation Test.
xi.
d.
Biceps Load Test II.
Diagnostic Testing Procedures:
i.
Radiographs are usually normal in isolated SLAP lesions. However, they can be useful in identifying
other sources of abnormalities.
ii.
Magnetic resonance imaging with arthrogram has the highest reported accuracy for both diagnosis and
classification of SLAP lesions; however, it may be difficult to differentiate SLAP lesions, especially Type II lesions,
from normal anatomic variants and from asymptomatic age related changes.
iii.
Arthroscopic evaluation is the most definitive diagnostic test.
e. Non-operative Treatment Procedures: Most SLAP lesions are associated with other pathology such as
rotator cuff tears, Bankart lesions, joint instability, biceps tendon tears, and supraspinatus tears. The provider should
refer to the treatment protocols for these conditions and follow both the surgical and non surgical recommendations.
For suspected isolated SLAP lesions, non invasive care, consider the following.
i.
Medications such as analgesics and anti-inflammatories may be helpful. (Refer to medication
discussions are in Medications.)
ii.
Therapeutic procedures may include instruction in therapeutic exercise and proper work techniques,
evaluation of occupational work station.
iii.
Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They
should include range-of-motion (ROM), active therapies, and a home exercise program. Passive as well as active
therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an
independent home exercise program targeted to further improve ROM and strength of the shoulder girdle
musculature. (Refer to Therapeutic Procedures, Non-operative.)
iv.
Subacromial bursal and/or glenohumeral steroid injections may decrease inflammation and allow the
therapist to progress with functional exercise and ROM.
(a). Time to Produce Effect: One injection.
(b). Maximum Duration: Three injections in one year at least four to eight weeks apart.
(c). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be
reminded to check their blood glucose levels at least daily for two weeks after injections.
v.
Return to work with appropriate restrictions should be considered early in the course of treatment.
Refer to Return to Work.
vi.
Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.
f. Surgical Indications: There is a significant amount of normal anatomic variation of the superior glenoid
labrum and origin of the long head of the biceps tendon. Differentiation between normal variation and pathology is
imperative.
i.
The physician should identify other shoulder pathology if any exists and follow the appropriate
surgical indications. If a SLAP lesion is suspected, an arthroscopic exam should be performed in conjunction with
the primary surgical procedure and an appropriate repair performed if necessary. See Specific Diagnosis Testing, &
Treatment related sections. Or;
ii.
When no additional pathology is identified and there is an inadequate response to at least three months
of non-operative management with active patient participation as evidenced by continued pain with functional
limitations and/or instability significantly affecting activities of daily living or work duties;
iii.
Prior to surgical intervention, the patient and treating physician should identify functional operative
goals and the likelihood of achieving improved ability to perform activities of daily living or work activities and the
patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The
patient should understand the length of partial and full disability expected post-operatively. The patient should also
understand that non-operative treatment is an acceptable option and that a potential complication of the surgery is
shoulder stiffness with pain and possibly decreased function.
g. Operative Procedures: Operative treatment of SLAP lesions depends on the type of lesion present and
whether any other intra-articular abnormalities are present. The following are generally accepted protocols for
surgical intervention; however, due to current lack of evidence, operative treatment is not limited to these.
i.
TypeI: Debridement is reasonable but not required.
ii.
TypeII: Repair via suture anchors or biceps tenotomy are reasonable options.
iii.
TypeIII: Debridement or excision of the bucket handle component alone or repair via suture anchors or
biceps tenotomy/tenodesis are reasonable options.
iv.
TypeIV: Debridement and/or biceps tenotomy or tenodesis are reasonable options.
h. Post-Operative Treatment: Post-operative rehabilitation programs should be individualized and
dependent upon whether any other intra-articular abnormalities exist and were operatively treated. There is a
paucity of information on rehabilitation of isolated SLAP lesions. Common post-operative care involves wearing a
sling, without active shoulder motion for 4 to 6 weeks. Elbow, wrist, and hand range-of-motion (ROM) exercises
may be used at this time. The sling is removed at 4 to 6 weeks and active ROM is usually begun with restrictions
directed by the surgeon. It is reasonable to restrict external rotation and abduction up to six months post-operative.
Return to work and restrictions after surgery may be made by an experienced primary occupational medicine
physician in consultation with the surgeon or by the surgeon.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1828 (June 2011).
§2325. Therapeutic ProceduresNon-Operative
A. Treating providers, as well as employers and insurers are highly encouraged to reference the General
Guideline Principles. Before initiation of any therapeutic procedure, the authorized treating provider, employer, and
insurer must consider these important issues in the care of the injured worker.
B. First, patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted
duty during their rehabilitation at the earliest appropriate time. Refer to “Return-to-Work” in this section for detailed
information.
C. Second, cessation and/or review of treatment modalities should be undertaken when no further significant
subjective or objective improvement in the patient’s condition is noted. If patients are not responding within the
recommended duration periods, alternative treatment interventions, further diagnostic studies or consultations should
be pursued.
D. Third, providers should provide and document education to the patient. No treatment plan is complete without
addressing issues of individual and/or group patient education as a means of facilitating self-management of
symptoms.
E. Lastly, formal psychological or psychosocial evaluation should be performed on patients not making expected
progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs
and tests.
F. In cases where a patient is unable to attend an outpatient center, skilled home therapy may be necessary.
Skilled home therapy may include active and passive therapeutic procedures as well as other modalities to assist in
alleviating pain, swelling, and abnormal muscle tone. Skilled home therapy is usually of short duration and
continues until the patient is able to tolerate coming to an outpatient center.
1. Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation, and there is
some scientific evidence to support its use. The exact mode of action is only partially understood. Western medicine
literature suggests that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation,
and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to
traditional Western pharmaceuticals. While it is commonly used when pain medication is reduced or not tolerated, it
may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the return to functional
activity. Acupuncture should be performed by licensed practitioners.
a. Acupuncture is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points).
Needles may be inserted, manipulated, and retained for a period of time. Acupuncture can be used to reduce pain,
reduce inflammation, increase blood flow, increase range of motion, decrease the side effect of medication-induced
nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
i.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, postsurgical pain relief, muscle spasm, and scar tissue pain.
b. Acupuncture with Electrical Stimulation: is the use of electrical current (micro-amperage or milliamperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous
stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release
for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain
stimulus, and muscle relaxation. It is indicated to treat chronic pain conditions, radiating pain along a nerve
pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.
c. Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation: Time frames are not
meant to be applied to each of the above sections separately. The time frames are to be applied to all acupuncture
treatments regardless of the type or combination of therapies being provided.
i.
Time to Produce Effect: three to ix treatments.
ii.
Frequency: one to three times per week.
iii.
Optimum Duration: one to two months.
iv.
Maximum Duration: 14 treatments.
(a). Any of the above acupuncture treatments may extend longer if objective functional gains can be
documented or when symptomatic benefits facilitate progression in the patient’s treatment program. Treatment
beyond 14 treatments must be documented with respect to need and ability to facilitate positive symptomatic or
functional gains. Such care should be re-evaluated and documented with each series of treatments.
d. Other Acupuncture Modalities: Acupuncture treatment is based on individual patient needs and therefore
treatment may include a combination of procedures to enhance treatment effect. Other procedures may include the
use of heat, soft tissue manipulation/massage, and exercise. Refer to Active Therapy (Therapeutic Exercise) and
Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these adjunctive
acupuncture modalities and time frames.
2. Biofeedback is a form of behavioral medicine that helps patients learn self-awareness and self-regulation
skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and
measures of autonomic nervous system activity. Electronic instrumentation is used to monitor the targeted
physiology and then displayed or fed back to the patient visually, auditorily, or tactilely, with coaching by a
biofeedback specialist. Biofeedback is provided by clinicians certified in biofeedback and/or who have documented
specialized education, advanced training, or direct or supervised experience qualifying them to provide the
specialized treatment needed (e.g., surface EMG, EEG, or other).
a. Treatment is individualized to the patient’s work-related diagnosis and needs. Home practice of skills is
required for mastery and may be facilitated by the use of home training tapes. The ultimate goal in biofeedback
treatment is normalizing the physiology to the pre-injury status to the extent possible and involves transfer of
learned skills to the workplace and daily life. Candidates for biofeedback therapy or training must be motivated to
learn and practice biofeedback and self-regulation techniques.
b. Indications for biofeedback include individuals who are suffering from musculoskeletal injury in which
muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays
recovery. Other applications include training to improve self-management of emotional stress/pain responses such as
anxiety, depression, anger, sleep disturbance, and other central and autonomic nervous system imbalances.
Biofeedback is often utilized along with other treatment modalities.
i.
Time to Produce Effect: three to four sessions.
ii.
Frequency: One to two times per week.
iii.
Optimum Duration: Five to six sessions.
iv.
Maximum Duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with
respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.
3. Extracorporeal Shock Wave Therapy (ESWT) is used to increase function and decrease pain in patients
with specified types of calcifying tendonitis who have failed conservative therapy. It is not a first line therapy.
ESWT uses acoustic impulses with duration in microseconds focused on the target tissue. The mechanism of action
is not known, but is not likely to be simply the mechanical disintegration of the calcium deposit. High-energy
application of ESWT may be painful, and rare complications such as osteonecrosis of the humeral head have been
reported. Dosage is established according to patient tolerance. Higher dosages are generally associated with better
functional results. There is good evidence that ESWT may improve pain and function in radiographically or
sonographically defined Type I or Type II calcium deposits when conservative treatment has failed to result in
adequate functional improvement, but optimal dosing has not been defined. In the absence of a documented calcium
deposit, there is no evidence that ESWT is effective and its use in this setting is not recommended. Neither
anesthesia nor conscious sedation is required nor is it recommended for this procedure. There is no evidence that
results with fluoroscopic guidance or with computer-assisted navigation are superior to results obtained by
palpation. These are not recommended.
a. Indicationspatients with calcifying tendonitis who have not achieved functional goals after two to three
months of active therapy. The calcium deposits must be Type I, homogenous calcification with well-defined borders
or Type II, heterogeneous with sharp border or homogenous with no defined border.
i.
Time to Produce Effect: Three days.
ii.
Frequency: Every four to seven days.
iii.
Optimum Duration: Two sessions. Progress can be documented by functional reports and/or x-ray or
sonographic decrease in calcium.
iv.
4.
Maximum Duration: Four sessions.
Injections-Therapeutic
a. Description. Therapeutic injection procedures are generally accepted, well-established procedures that
may play a significant role in the treatment of patients with upper extremity pain or pathology. Therapeutic
injections involve the delivery of anesthetic and/or anti-inflammatory medications to the painful structure.
Therapeutic injections have many potential benefits. Ideally, a therapeutic injection will: reduce inflammation in a
specific target area; relieve secondary muscle spasm; allow a break from pain; and support therapy directed to
functional recovery. Diagnostic and therapeutic injections should be used early and selectively to establish a
diagnosis and support rehabilitation. If injections are overused or used outside the context of a monitored
rehabilitation program, they may be of significantly less value.
b. Indications. Diagnostic injections are procedures which may be used to identify pain generators or
pathology. For additional specific clinical indications, see Specific Diagnosis, Testing and Treatment Procedures.
c. Contraindications - General contraindications include local or systemic infection, bleeding disorders,
allergy to medications used and patient refusal. Specific contraindications may apply to individual injections.
i.
Shoulder Joint Injections: are generally accepted, well-established procedures that can be performed as
analgesic or anti-inflammatory procedures. Common shoulder joint injections include anterior and posterior
glenohumeral and acromioclavicular.
(a). Time to Produce Effect: Immediate with local anesthesia, or within 3 days if no anesthesia.
(b). Optimum Duration: Usually One or two injections are adequate.
(c). Maximum Duration: Not more than three to four times annually.
(d). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be
reminded to check their blood glucose level at least daily for two weeks post injections.
ii.
Subacromial Injections There is good evidence that blinded subacromial blocks are not accurate. Up to
a third of blinded injections may involve the cuff and are likely to cause pain. This may lead to an incorrect
diagnosis when the injection is being used diagnostically. (Refer to Diagnostic injections) If there is a concern
regarding needle placement, sonography or fluoroscopy may be used.
iii.
Soft Tissue Injections: include bursa and tendon insertions. Injections under significant pressure should
be avoided as the needle may be penetrating the tendon. Injection into the tendon can cause tendon degeneration,
tendon breakdown, or rupture. Injections should be minimized for patients under 30 years of age. Steroid injections
should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose
level at least daily for two weeks post injections. The risk of tendon rupture should be discussed with the patient and
the need for restricted duty emphasized.
(a). Frequency: Usually one or two injections are adequate.
(b). Time to Produce Effect: Immediate with local anesthesia, or within three days if no anesthesia.
(c). Optimum/Maximum Duration: Three steroid injections at the same site per year.
iv.
Trigger Point Injections: although generally accepted, are not routinely used in the shoulder. However,
it is not unusual to find shoulder girdle myofascial trigger points associated with shoulder pathology which may
require injections.
(a). Description. Trigger point treatment can consist of dry needling or injection of local anesthetic with
or without corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local
and referred pain when activated. Medication is injected in a four-quadrant manner in the area of maximum
tenderness. Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic
interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue
mobilization and physical modalities. There is conflicting evidence regarding the benefit of trigger point injections.
A truly blinded study comparing dry needle treatment of trigger points is not feasible. There is no evidence that
injection of medications improves the results of trigger-point injections. Needling alone may account for some of the
therapeutic response.
(i). There is no indication for conscious sedation for patients receiving trigger point injections. The
patient must be alert to help identify the site of the injection.
(b). Indications. Trigger point injections may be used to relieve myofascial pain and facilitate active
therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in combination with
other treatment modalities such as functional restoration programs. Trigger point injections should be utilized
primarily for the purpose of facilitating functional progress. Patients should continue with a therapeutic exercise
program as tolerated throughout the time period they are undergoing intensive myofascial interventions. Myofascial
pain is often associated with other underlying structural problems and any abnormalities need to be ruled out prior to
injection.
(i). Trigger point injections are indicated in those patients where well circumscribed trigger points
have been consistently observed, demonstrating a local twitch response, characteristic radiation of pain pattern and
local autonomic reaction, such as persistent hyperemia following palpation. Generally, these injections are not
necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial
interventions within approximately a 6-week time frame.
(ii). Complications. Potential but rare complications of trigger point injections include infection,
pneumothorax, anaphylaxis, neurapraxia, and neuropathy. If corticosteroids are injected in addition to local
anesthetic, there is a risk of local developing myopathy. Severe pain on injection suggests the possibility of an
intraneural injection, and the needle should be immediately repositioned.
[a]. Time to Produce Effect: Local anesthetic 30 minutes; no anesthesia 24 to 48 hours.
[b]. Frequency: Weekly, suggest no more than four injection sites per session per week to avoid
significant post-injection soreness.
[c]. Optimum Duration: Four Weeks.
[d]. Maximum Duration: Eight weeks. Occasional patients may require two to four repetitions of
trigger point injection series over a one to two year period.
v.
Prolotherapy: (also known as Sclerotherapy/Regenerative Injection Therapy) consists of peri- or intraligamentous injections of hypertonic dextrose with or without phenol with the goal of inducing an inflammatory
response that will recruit cytokine growth factors involved in the proliferation of connective tissue. Advocates of
prolotherapy propose that these injections will alleviate complaints related to joint laxity by promoting the growth of
connective tissue and stabilizing the involved joint.
(a). Laboratory studies may lend some biological plausibility to claims of connective tissue growth, but
high quality published clinical studies are lacking. The dependence of the therapeutic effect on the inflammatory
response is poorly defined, raising concerns about the use of conventional anti-inflammatory drugs when proliferant
injections are given. The evidence in support of prolotherapy is insufficient and therefore, its use is not
recommended in upper extremity injuries.
vi.
Viscosupplementation/Intracapsular Acid Salts: involves the injection of hyaluronic acid and its
derivatives into the glenohumeral joint space. Hyaluronic acid is secreted into the joint space by the healthy
synovium and has functions of lubrication and cartilage protection. Its use in the shoulder is not supported by
scientific evidence at this time.
5. Jobsite Alteration. Early evaluation and training of body mechanics are essential for every injured worker.
Risk factors to be addressed include repetitive overhead work, lifting and/or tool use. In some cases, this requires a
jobsite evaluation. Some evidence supports alteration of the work site in the early treatment of shoulder injuries.
There is no single factor or combination of factors that is proven to prevent or ameliorate shoulder pain, but a
combination of ergonomic and psychosocial factors are generally considered to be important. Physical factors that
may be considered include use of force, repetitive overhead work, and awkward overhead positions requiring use of
force, upper extremity vibration, and contact pressure on the nerve. Psychosocial factors to be considered include
pacing, degree of control over job duties, perception of job stress, and supervisory support. The job analysis and
modification should include input from the employee, employer, and ergonomist or other professional familiar with
work place evaluation. The employee must be observed performing all job functions in order for the jobsite analysis
to be valid. Periodic follow-up is recommended to evaluate effectiveness of the intervention and need for additional
ergonomic changes.
a. Ergonomic Changes may be made to modify the hazards identified. In addition, workers should be
counseled to vary tasks throughout the day whenever possible. OSHA suggests that workers’ who perform overhead
repetitive tasks with or without force, take 15 to 30 second breaks every 10 to 20 minutes, or 5-minute breaks every
hour. Mini-breaks should include stretching exercises.
b. Interventions should consider engineering controls (e.g., mechanizing the task, changing the tool used, or
adjusting the jobsite), or administrative controls (e.g., adjusting the time an individual performs the task).
6. Medications for the treatment of upper extremity injuries is appropriate to control acute pain and
inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to
complicated fractures. All drugs should be used according to patient needs. A thorough medication history, including
use of alternative and over the counter medications, should be performed at the time of the initial visit and updated
periodically. Treatment for pain control is initially accomplished with acetaminophen and/or NSAIDs. The patient
should be educated regarding the interaction with prescription and over-the-counter medications as well as the
contents of over-the-counter herbal products.
a. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of
injuries associated with degenerative joint disease and/or inflammation. These same medications can be used for
pain control.
b. Topical agents may be beneficial for pain management in some patients with upper extremity injuries.
This includes topical capsaicin, nonsteroidal, as well as, topical iontphoretics/phonophoretics, such as steroid creams
and lidocaine.
c.
The following are listed in alphabetical order.
i.
Acetaminophen is an effective analgesic with antipyretic but not anti-inflammatory activity.
Acetaminophen is generally well tolerated, causes little or no gastrointestinal irritation and is not associated with
ulcer formation. Acetaminophen has been associated with liver toxicity in overdose situations or in chronic alcohol
use. Patients may not realize that many over-the-counter preparations may contain acetaminophen. The total daily
dose of acetaminophen is recommended not to exceed 2250 mg per 24 hour period, from all sources, including
narcotic-acetaminophen combination preparations.
(a). Optimum Duration: 7 to 10 days.
(b). Maximum Duration: Chronic use as indicated on a case-by-case basis. Use of this substance longterm for three days per week or greater may be associated with rebound pain upon cessation.
ii.
Minor Tranquilizer/Muscle Relaxants are appropriate for muscle spasm, mild pain and sleep disorders.
When prescribing these agents, physicians must seriously consider side effects of drowsiness or dizziness and the
fact that benzodiazepines may be habit-forming.
(a). Optimum Duration: Up to one week.
(b). Maximum Duration: Four weeks.
iii.
Narcotics should be primarily reserved for the treatment of severe upper extremity pain. There are
circumstances where prolonged use of narcotics is justified based upon specific diagnosis and in pre- and post–
operative patients. In these and other cases, it should be documented and justified. In mild-to-moderate cases of
upper extremity pain, narcotic medication should be used cautiously on a case-by-case basis. Adverse effects include
respiratory depression, the development of physical and psychological dependence, and impaired alertness.
(a). Narcotic medications should be prescribed with strict time, quantity, and duration guidelines, and
with definitive cessation parameters. Pain is subjective in nature and should be evaluated using a pain scale and
assessment of function to rate effectiveness of the narcotic prescribed. Any use beyond the maximum should be
documented and justified based on the diagnosis and/or invasive procedures.
(i). Optimum Duration: Up to 10 days.
(ii). Maximum Duration: Two weeks for most non-operative cases. Use beyond two weeks is
acceptable in appropriate cases. Refer to Chronic Pain Guidelines which provides a detailed discussion regarding
medication use in chronic pain management.
iv.. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are useful for pain and inflammation. In mild cases,
they may be the only drugs required for analgesia. There are several classes of NSAIDs, and the response of the
individual injured worker to a specific medication is unpredictable. For this reason, a range of NSAIDs may be tried
in each case with the most effective preparation being continued. Patients should be closely monitored for adverse
reactions. The US Food and Drug Administration advises that many NSAIDs may cause an increased risk of serious
cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. Naproxen sodium does not
appear to be associated with increased risk of vascular events. Administration of proton pump inhibitors, Histamine
2 Blockers, or prostaglandin analog misoprostol along with these NSAIDs may reduce the risk of duodenal and
gastric ulceration but do not impact possible cardiovascular complications. Due to the cross-reactivity between
aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all
asthma patients. NSAIDs are associated with abnormal renal function, including renal failure, as well as, abnormal
liver function. Certain NSAIDs may have interactions with various other medications. Individuals may have
adverse events not listed above. Intervals for metabolic screening are dependent upon the patient's age, general
health status and should be within parameters listed for each specific medication. Complete Blood Count (CBC) and
liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially
when indicated.
(a). Non-selective Nonsteroidal Anti-Inflammatory Drugs:
(i). Includes NSAIDs, and acetylsalicylic acid (aspirin). Serious GI toxicity, such as bleeding,
perforation, and ulceration can occur at any time, with or without warning symptoms in patients treated with
traditional NSAIDs. Physicians should inform patients about the signs and/or symptoms of serious gastrointestinal
toxicity and what steps to take if they occur. Anaphylactoid reactions may occur in patients taking NSAIDs. NSAIDs
may interfere with platelet function. Fluid retention and edema have been observed in some patients taking NSAIDs.
[a]. Optimal Duration: One week.
[b]. Maximum Duration: One year. Use of these substances long-term (Three days per week or
greater) is associated with rebound pain upon cessation.
(b). Selective Cyclo-oxygenase-2 (COX-2) Inhibitors:
(i). COX-2 inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the
traditional NSAIDs. The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have
less gastrointestinal toxicity and no platelet effects. COX-2 inhibitors can worsen renal function in patients with
renal insufficiency, thus renal function may need monitoring.
(ii). COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short
term but are indicated in select patients for whom traditional NSAIDs are not tolerated. Serious upper GI adverse
events can occur even in asymptomatic patients. Patients at high risk for GI bleed include those who use alcohol,
smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy. Celecoxib is
contraindicated in sulfonamide allergic patients.
[a]. Optimal Duration: 7 to 10 days.
[b]. Maximum Duration: Chronic use is appropriate in individual cases. Use of these substances longterm (three days per week or greater) is associated with rebound pain upon cessation.
v.
Oral Steroids: have limited use but are accepted in cases requiring potent anti-inflammatory drug effect
in carefully selected patients. A one-week regime of steroids may be considered in the treatment of patients who
have arthritic flare-ups with significant inflammation of the joint. The physician must be fully aware of potential
contraindications for the use of all steroids such as avascular necrosis, hypertension, diabetes, glaucoma, peptic ulcer
disease, etc., which should be discussed with the patient.
(a). Optimal Duration: Three to seven days.
(b). Maximum Duration: Seven days.
vi.
Psychotropic/Anti-anxiety/Hypnotic Agents: may be useful for treatment of mild and chronic pain,
dysesthesia, sleep disorders, and depression. Antidepressant medications, such as tricyclics and Selective Serotonin
Reuptake inhibitors (SSRIs) and Selective serotonin norephrine reuptake inhibitors (SSNRIs), are useful for
affective disorder and chronic pain management. Tricyclic antidepressant agents, in low dose, are useful for chronic
pain but have more frequent side effects.
(a). Anti-anxiety medications are best used for short-term treatment (i.e., less than six months).
Accompanying sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently,
combinations of the above agents are useful. As a general rule, physicians should access the patient’s prior history of
substance abuse or depression prior to prescribing any of these agents.
(b). Due to the habit-forming potential of the benzodiazepines and other drugs found in this class, they
are not routinely recommended. Refer to the Chronic Pain Guidelines which give a detailed discussion regarding
medication use in chronic pain management.
(i). Optimum Duration: One to six months.
(ii). Maximum Duration: 6 to 12 months, with monitoring.
vii.. Tramadol is useful in relief of upper extremity pain and has been shown to provide pain relief
equivalent to that of commonly prescribed NSAIDs. Tramadol is an atypical opioid with norepinephrine and
serotonin reuptake inhibition. It is not considered a controlled substance in the U.S. Although tramadol may cause
impaired alertness it is generally well tolerated, does not cause gastrointestinal ulceration, or exacerbate
hypertension or congestive heart failure. Tramadol should be used cautiously in patients who have a history of
seizures or who are taking medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and
tricyclic antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt
discontinuation and is not recommended for patients with prior opioid addiction.
(a). Optimum Duration: Three to seven days.
(b). Maximum Duration: Two weeks. Use beyond two weeks is acceptable in appropriate cases.
viii.
Topical Drug Delivery. Creams and patches may be an alternative treatment of localized
musculoskeletal disorders. It is necessary that all topical agents be used with strict instructions for application as
well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. As with
all medications, patient selection must be rigorous to select those patients with the highest probability of
compliance.
(a). Topical Salicylates and Nonsalicylates have been shown to be effective in relieving pain in acute and
chronic musculoskeletal conditions. Topical salicylate and nonsalicylates achieve tissue levels that are potentially
therapeutic, at least with regard to COX inhibition. Other than local skin reactions, the side effects of therapy are
minimal, although not nonexistent, and the usual contraindications to use of these compounds needs to be
considered. Local skin reactions are rare and systemic effects were even less common. Their use in patients
receiving warfarin therapy may result in alterations in bleeding time. Overall, the low level of systemic absorption
can be advantageous; allowing the topical use of these medications when systemic administration is relatively
contraindicated such as is the case in patients with hypertension, cardiac failure, or renal insufficiency.
(b). There is no evidence that topical agents are more effective than oral medications. Therefore, they
should not generally be used unless the patient has an intolerance to anti-inflammatories.
(i). Optimum Duration: One week.
(ii). Maximum Duration: Two weeks per episode.
(c). Capsaicin is another medication option for topical drug use in upper extremity injury. Capsaicin
offers a safe and effective alternative to systemic NSAID therapy. Although it is quite safe, effective use of capsaicin
is limited by the local stinging or burning sensation that typically dissipates with regular use, usually after the first 7
to 10 days of treatment. Patients should be advised to apply the cream on the affected area with a plastic glove or
cotton applicator and to avoid inadvertent contact with eyes and mucous membranes.
(i). Optimum Duration: One week.
(ii). Maximum Duration: Two weeks per episode.
(d). Other Agents. Other topical agents, including prescription drugs (i.e., lidocaine), prescription
compound agents, and prescribed over-the-counter medications (i.e., blue ice), may be useful for pain and
inflammation. These drugs should be used according to patient needs.
(i). Optimum Duration: Varies with drug or compound.
(ii). Maximum Duration: Varies with drug or compound.
(e). Iontophoretic Agents: Refer to Iontophoresis under Passive Therapy of this section.
7.
Occupational Rehabilitation Programs
a. Non-Interdisciplinary. These generally accepted programs are work-related, outcome-focused,
individualized treatment programs. Objectives of the program include, but are not limited to, improvement of
cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability, and
motor control functions), patient education, and symptom relief. The goal is for patients to gain full or optimal
function and return to work. The service may include the time-limited use of passive modalities with progression to
achieve treatment and/or simulated/real work. These programs are frequently necessary for patients who must return
to physically demanding job duties or whose injury requires prolonged rehabilitation and therapy spanning several
months.
i.
Work Conditioning. These programs are usually initiated once reconditioning has been completed, but
may be offered at any time throughout the recovery phase. It should be initiated when imminent return of a patient to
modified or full duty is not an option, but the prognosis for returning the patient to work at completion of the
program is at least fair to good.
(a). Length of visit: One to two hours per day.
(b). Frequency: Two to five visits per week.
(c). Optimum Duration: Two to five weeks.
(d). Maximum Duration: Six weeks. Participation in a program beyond six weeks must be documented
with respect to need and the ability to facilitate positive symptomatic or functional gains.
ii.
Work Simulation. Work Simulation is a program where an individual completes specific work-related
tasks for a particular job and return to work. Use of this program is appropriate when modified duty can only be
partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient
requires more structured supervision. The need for work place simulation should be based upon the results of a
Functional Capacity Evaluation and/or Jobsite Analysis.
(a). Length of visit: Two to six hours per day.
(b). Frequency: Two to five visits per week.
(c). Optimum Duration: Two to four weeks.
(d). Maximum Duration. Six weeks. Participation in a program beyond six weeks must be documented
with respect to need and the ability to facilitate positive symptomatic or functional gains.
b. Interdisciplinary. These generally accepted programs are characterized by a variety of disciplines that
participate in the assessment, planning, and/or implementation of an injured workers program with the goal for
patients to gain full or optimal function and return to work. There should be close interaction and integration among
the disciplines to ensure that all members of the team interact to achieve team goals. These programs are for patients
with greater levels of perceived disability, dysfunction, de-conditioning and psychological involvement. For patients
with chronic pain, refer to the OWCA’s Chronic Pain Disorder Medical Treatment Guidelines.
i
Work Hardening. Work Hardening is an interdisciplinary program addressing a patient’s employability
and return to work. It includes a progressive increase in the number of hours per day that a patient completes work
simulation tasks until the patient can tolerate a full workday. This is accomplished by addressing the medical,
psychological, behavioral, physical, functional, and vocational components of employability and return-to-work.
ii.
This can include a highly structured program involving a team approach or can involve any of the
components thereof. The interdisciplinary team should, at a minimum, be comprised of a qualified medical director
who is board certified with documented training in occupational rehabilitation; team physicians having experience in
occupational rehabilitation, occupational therapist; physical therapist; case manager; and psychologist. As
appropriate, the team may also include: chiropractor, RN, or vocational specialist or Certified Biofeedback
Therapist.
(a). Length of visit: Up to eight hours/day.
(b). Frequency: Two to five visits per week.
(c). Optimum Duration: Two to four weeks.
(d). Maximum Duration. Six weeks. Participation in a program beyond six weeks must be documented
with respect to need and the ability to facilitate positive symptomatic or functional gains.
8.
Orthotics and Prosthetics
a. Fabrication/Modification of Orthotics facilitate better motion response, stabilize a joint with insufficient
muscle or proprioceptive/reflex competencies, to protect subacute conditions as needed during movement, and
correct biomechanical problems. For specific types of orthotics/prosthetics, refer to Specific Diagnosis, Testing and
Treatment Procedures.
i.
Time to Produce Effect: One to three sessions (includes wearing schedule evaluation).
ii.
Frequency: One to two times per week.
iii.
Optimum/Maximum Duration: Four sessions of evaluation, casting, fitting, and re-evaluation.
b. Orthotic/Prosthetic Training is the skilled instruction (preferably by qualified providers) in the proper use
of orthotic devices and/or prosthetic limbs including stump preparation, donning and doffing limbs, instruction in
wearing schedule and orthotic/prosthetic maintenance training. Training can include activities of daily living and
self-care techniques.
i.
Time to Produce Effect: Two to six sessions.
ii.
Frequency: Three times per week.
iii.
Optimum/Maximum Duration: Two to four months.
c. Splints or adaptive equipment design, fabrication and/or modification indications include the need to
control neurological and orthopedic injuries for reduced stress during functional activities and modify tasks through
instruction in the use of a device or physical modification of a device, which reduces stress on the injury. Equipment
should improve safety and reduce risk of re-injury. This includes high and low technology assistive options such as
workplace modifications, computer interface or seating, and self-care aids.
i.
Time to Produce Effect: Immediate.
ii.
Frequency: One to three sessions or as indicated to establish independent use.
iii.
Optimum/Maximum Duration: One to three sessions.
9. Patient Education. No treatment plan is complete without addressing issues of individual and/or group
patient education as a means of prolonging the beneficial effects of treatment, as well as facilitating selfmanagement of symptoms and injury prevention. The patient should be encouraged to take an active role in the
establishment of functional outcome goals. They should be educated on their specific injury, assessment findings,
and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid, self-care for
exacerbation of symptoms, and home exercise should also be addressed.
a.
Time to Produce Effect: Varies with individual patient.
b.
Frequency: Should occur at each visit.
10. Personality/Psychosocial/Psychiatric/Psychological Intervention. Psychosocial treatment is generally
accepted widely used and well-established intervention. This group of therapeutic and diagnostic modalities
includes, but is not limited to, individual counseling, group therapy, stress management, psychosocial crises
intervention, hypnosis and meditation. Any evaluation or diagnostic workup should clarify and distinguish between
pre-existing versus aggravated versus purely causative psychological conditions. Psychosocial intervention is
recommended as an important component in the total management program that should be implemented as soon as
the problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers
treating patients with chronic pain should refer to the OWCA’s Chronic Pain Disorder Medical Treatment
Guidelines.
a.
Time to Produce Effect: Two to four weeks.
b. Frequency: One to three times weekly for the first four weeks (excluding hospitalization, if required),
decreasing to one to two times per week for the second month. Thereafter, two to four times monthly.
c.
Optimum Duration: Six weeks to three months.
d. Maximum Duration. 3 to 12 months. Counseling is not intended to delay but to enhance functional
recovery. For select patients, longer supervised treatment may be required, and if further counseling beyond 3
months is indicated, extensive documentation addressing which pertinent issues are pre-existing versus aggravated
versus causative, as well as projecting a realistic functional prognosis, should be provided by the authorized treating
provider every 4 to 6 weeks during treatment.
11. Restriction of Activities varies according to the specific diagnosis and the severity of the condition. Job
modification/modified duty are frequently required to avoid exacerbation of the injured shoulder. Complete work
cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-towork is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with upper
extremity injuries.
12. Return-to-work. Early return-to-work should be a prime goal in treating occupational injuries given the poor
return-to-work prognosis for an injured worker who has been out of work for more than six months. It is imperative
that the patient be educated regarding the benefits of return-to-work, work restrictions, and follow-up if problems
arise. When attempting to return a patient to work after a specific injury, clear objective restrictions of activity level
should be made. An accurate job description with detailed physical duty restrictions is often necessary to assist the
physician in making return-to-work recommendations. This may require a jobsite evaluation.
a. Employers should be prepared to offer transitional work. This may consist of temporary work in a less
demanding position, return to the regular job with restrictions, or gradual return to the regular job. Company policies
which encourage return-to-work with positive communication are most likely to have decreased worker disability.
b. Return-to-work is defined as any work or duty that the patient is able to perform safely. It may not be the
patient’s regular work. Due to the large spectrum of injuries of varying severity and varying physical demands in the
work place, it is not possible to make specific return-to-work guidelines for each injury. Therefore, the OWCA
recommends the following:
i.
Establishment of a Return-to-Work Status. Ascertaining a return-to-work status is part of medical care,
should be included in the treatment and rehabilitation plan, and addressed at every visit. A description of daily
activity limitations is part of any treatment plan and should be the basis for restriction of work activities. In most
non-surgical cases the patient should be able to return to work in some capacity or in an alternate position consistent
with medical treatment within several days unless there are extenuating circumstances. Injuries requiring more than
two weeks off work should be thoroughly documented. Refer to Specific Diagnoses in Post-operative Return to
Work Subsections.
ii.
Establishment of Activity Level Restrictions. Communication is essential between the patient,
employer and provider to determine appropriate restrictions and return-to-work dates. It is the responsibility of the
physician to provide clear, concise restrictions, and it is the employer’s responsibility to determine if temporary
duties can be provided within the restrictions. For shoulder injuries, the following should be addressed when
describing the patient’s activity level:
(a). Activities such as overhead motion, lifting, abduction;
(b). Static shoulder positions with regard to duration and frequency;
(c). Use of adaptive devices or equipment for proper ergonomics and to enhance capacities;
(d). Maximum lifting limits with reference to the frequency of the lifting and/or the object height level;
and
(e). Maximum limits for pushing, pulling, with limits on bending and twisting at the waist as necessary.
iii.
Compliance with Activity Restrictions. In some cases, compliance with restriction of activity levels
may require a complete jobsite evaluation, a functional capacity evaluation (FCE), or other special testing. Refer to
“Special Tests” of this section.
13. Therapy-Active
a. The following active therapies are widely used and accepted methods of care for a variety of workrelated injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for
restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort. Active therapy
requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires
supervision from a therapist or medical provider such as verbal, visual and/or tactile instruction(s). At times, the
provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is
predominately executed by the patient.
b. Patients should be instructed to continue active therapies at home as an extension of the treatment
process in order to maintain improvement levels. Follow-up visits to reinforce and monitor progress and proper
technique are recommended. Home exercise can include exercise with or without mechanical assistance or
resistance and functional activities with assistive devices. Frequency times and duration of treatment apply only to
diagnoses not previously covered in Section E.
i.
Activities of Daily Living (ADL) are well-established interventions which involve instruction, activeassisted training, and/or adaptation of activities or equipment to improve a person's capacity in normal daily
activities such as self-care, work re-integration training, homemaking, and driving.
(a). Time to Produce Effect: Four to five treatments.
(b). Frequency: Three to five times per week.
(c). Optimum Duration: Four to six weeks.
(d). Maximum Duration: Six weeks.
ii.
Aquatic Therapy is a well-accepted treatment which consists of the therapeutic use of aquatic
immersion for therapeutic exercise to promote ROM, flexibility, strengthening, core stabilization, endurance, body
mechanics, and pain management. Aquatic therapy includes the implementation of active therapeutic procedures in a
swimming or therapeutic pool. The water provides a buoyancy force that lessens the amount of force gravity applies
to the body. The decreased gravity effect allows the patient to have a mechanical advantage and more likely to have
a successful trial of therapeutic exercise. Literature has shown that the muscle recruitment for aquatic therapy versus
similar non–aquatic motions is significantly less. Because there is always a risk of recurrent or additional damage to
the muscle tendon unit after a surgical repair, aquatic therapy may be preferred by surgeons to gain early return of
ROM. In some cases the patient will be able to do the exercises unsupervised after the initial supervised session.
Parks and recreation contacts may be used to locate less expensive facilities for patients. Indications include:
(a). Postoperative therapy as ordered by the surgeon;
(b). Intolerance for active land-based or full-weight bearing therapeutic procedures;
(c). Symptoms that are exacerbated in a dry environment; and/or
(d). Willingness to follow through with the therapy on a regular basis.
iii.
The pool should be large enough to allow full extremity ROM and fully erect posture. Aquatic vests,
belts, snorkels, and other devices may be used to provide stability, balance, buoyancy, and resistance.
(a). Time to Produce Effect: Four to five treatments.
(b). Frequency: Three to five times per week.
(c). Optimum Duration: Four to six weeks.
(d). Maximum Duration: Eight weeks.
iv.
A self-directed program is recommended after the supervised aquatics program has been established,
or, alternatively a transition to a self-directed dry environment exercise program.
v.
Functional Activities are well-established interventions which involve the use of therapeutic activity to
enhance mobility, body mechanics, employability, coordination, balance, and sensory motor integration.
(a). Time to Produce Effect: Four to five treatments.
(b). Frequency: Three to five times per week.
(c). Optimum Duration: Four to six weeks.
(d). Maximum Duration: Six weeks.
vi.
Functional Electrical Stimulation is an accepted treatment in which the application of electrical current
to elicit involuntary or assisted contractions of atrophied and/or impaired muscles. Indications include muscle
atrophy, weakness, and sluggish muscle contraction secondary to pain, injury, neuromuscular dysfunction or
peripheral nerve lesion. Indications also may include an individual who is precluded from active therapy.
(a). Time to Produce Effect: Two to six treatments.
(b). Frequency: Three times per week.
(c). Optimum Duration: Eight weeks.
(d). Maximum Duration: Eight weeks. If functional gains are documented by a therapist, a home unit
may be provided.
vii.
Neuromuscular Re-education is a generally accepted treatment. It is the skilled application of exercise
with manual, mechanical, or electrical facilitation to enhance strength; movement patterns; neuromuscular response;
proprioception; kinesthetic sense; coordination; education of movement, balance and posture. Indications include the
need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve
motor activity in patterns similar to normal neurologically developed sequences, and to improve neuromotor
response with independent control.
(a). Time to Produce Effect: Two to six treatments.
(b). Frequency: Three times per week.
(c). Optimum Duration: Four to eight weeks.
(d). Maximum Duration: Eight weeks.
viii.
Therapeutic Exercise is a generally well-accepted treatment. Therapeutic exercise, with or without
mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises.
The exact type of program and length of therapy should be determined by the treating physician with the physical or
occupational therapist. Refer to Specific Diagnosis, Testing and Treatment Procedures regarding specific diagnoses
for details. In most cases, the therapist instructs the patient in a supervised clinic and home program to increase
motion and subsequently increase strength. Usually, isometrics are performed initially, progressing to isotonic
exercises as tolerated.
(a). Time to Produce Effect: Two to six treatments.
(b). Frequency: Two to three times per week.
(c). Optimum Duration: 16 to 24 sessions.
(d). Maximum Duration. 36 sessions. Additional visits may be necessary in cases of re-injury, interrupted
continuity of care, exacerbation of symptoms, and in those patients with co-morbidities. Functional gains including
increased ROM must be demonstrated to justify continuing treatment.
14. Therapy-Passive. Most of the following passive therapies and modalities are generally accepted methods of
care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require
energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and
are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft
tissue injuries. They should be used adjunctively with active therapies to help control swelling, pain, and
inflammation during the rehabilitation process. They may be used intermittently as a therapist deems appropriate or
regularly if there are specific goals with objectively measured functional improvements during treatment.
a. On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond
those listed as "maximum.” Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and
comorbidities may also extend durations of care. Specific goals with objectively measured functional improvement
during treatment must be cited to justify extended durations of care. It is recommended that, if no functional gain is
observed after the number of treatments under “time to produce effect” have been completed, alternative treatment
interventions, further diagnostic studies, or further consultations should be pursued.
b.
i.
The following passive therapies and modalities are listed in alphabetical order.
Continuous Passive Movement (CPM): Refer to Rotator Cuff Tear.
ii.
Electrical Stimulation (Unattended is an accepted treatment. Unattended electrical stimulation once
applied, requires minimal on-site supervision by the physician or non-physician provider. Indications include pain,
inflammation, muscle spasm, atrophy, decreased circulation, and the need for osteogenic stimulation.
(a). Time to Produce Effect: Two to four treatments.
(b). Frequency. Varies. Depending upon indication, between two to three times per day to one time a
week. Provide home unit if frequent use.
(c). Optimum Duration: One to three months.
(d). Maximum Duration: Three months.
iii.
Hyperbaric Oxygen Therapy. There is no evidence to support long-term benefit of hyperbaric oxygen
therapy for non-union upper extremity fractures. It is not recommended.
iv.
Immobilization: Time is dependent upon type of injury.
(a). Time to Produce Effect: One day.
(b). Frequency: Once.
(c). Optimum Duration: One week.
(d). Maximum Duration: 12 weeks.
(e). The arm may be immobilized in a sling for 1 to 12 weeks post-injury, depending upon the age of the
patient and diagnosis. The patient is instructed in isometric exercises while in the sling for the internal and external
rotators and the deltoid.
v.
Iontophoresis is an accepted treatment which consists of the transfer of medication, including, but not
limited to, steroidal anti-inflammatory and anesthetics, through the use of electrical stimulation. Indications include
pain (Lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, salicylate), ischemia
(magnesium, mecholyl, iodine), muscle spasm (magnesium, calcium), calcifying deposits (acetate), scars, and
keloids (chlorine, iodine, acetate).
(a). Time to Produce Effect: One to four treatments.
(b). Frequency: 3 times per week with at least 48 hours between treatments.
(c). Optimum Duration: 8 to 10 treatments.
(d). Maximum Duration: 10 treatments.
vi.
Manipulation is a generally accepted, well-established and widely used therapeutic intervention for
shoulder injuries. Manipulative treatment (not therapy) is defined as the therapeutic application of manually guided
forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury
or occupational disease, and has associated clinical significance.
(a). High velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic
manipulation, muscle energy techniques, counter strain, and non-force techniques are all types of manipulative
treatment. This may be applied by osteopathic physicians (D.O.), chiropractors (D.C.), properly trained physical
therapists (P.T.), properly trained occupational therapists (O.T.), or properly trained medical physicians. Under these
different types of manipulation exist many subsets of different techniques that can be described as direct- a forceful
engagement of a restrictive/pathologic barrier, indirect- a gentle/non-forceful disengagement of a
restrictive/pathologic barrier, the patient actively assists in the treatment and the patient relaxing, allowing the
practitioner to move the body tissues. When the proper diagnosis is made and coupled with the appropriate
technique, manipulation has no contraindications and can be applied to all tissues of the body. Pre-treatment
assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and
correct treatment is employed.
(i). Time to Produce Effect for all types of manipulative treatment: One to six treatments.
(ii). Frequency: Up to three times per week for the first three weeks as indicated by the severity of
involvement and the desired effect.
(iii). Optimum Duration: 10 treatments.
(iv). Maximum Duration. 12 treatments. Additional visits may be necessary in cases of re-injury,
interrupted continuity of care, exacerbation of symptoms, and in those patients with co-morbidities. Functional gains
including increased ROM must be demonstrated to justify continuing treatment.
vii.
Manual Electrical Stimulation is used for peripheral nerve injuries or pain reduction that requires
continuous application, supervision, or involves extensive teaching. Indications include muscle spasm (including
TENS), atrophy, decreased circulation, osteogenic stimulation, inflammation, and the need to facilitate muscle
hypertrophy, muscle strengthening, muscle responsiveness in Spinal Cord Injury/Brain Injury (SCI/BI), and
peripheral neuropathies.
(a). Time to Produce Effect: Variable, depending upon use.
(b). Frequency: Three to seven times per week.
(c). Optimum Duration: Eight weeks.
(d). Maximum Duration: Two months.
viii.
MassageManual or Mechanical. Massage is manipulation of soft tissue with broad ranging
relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels
(acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft
tissues by, or with, the practitioner’s hands. Indications include edema (peripheral or hard and non-pliable edema),
muscle spasm, adhesions, the need to improve peripheral circulation and ROM, or to increase muscle relaxation and
flexibility prior to exercise. In cases with edema, deep vein thrombosis should be ruled out prior to treatment.
(a). Time to Produce Effect: Immediate.
(b). Frequency: One to two times per week.
(c). Optimum Duration: Six weeks.
(d). Maximum Duration: Two months.
ix.
Mobilization (Joint) is a generally well-accepted treatment. Mobilization is passive movement which
may include passive ROM performed in such a manner (particularly in relation to the speed of the movement) that it
is, at all times, within the ability of the patient to prevent the movement if they so choose. It may include skilled
manual joint tissue stretching. Indications include the need to improve joint play, improve intracapsular
arthrokinematics, or reduce pain associated with tissue impingement/maltraction.
(a). Time to Produce Effect: Six to nine treatments.
(b). Frequency: Three times per week.
(c). Optimum Duration: Six weeks.
(d). Maximum Duration: Two months.
x.
Mobilization (Soft Tissue) is a generally well-accepted treatment. Mobilization of soft tissue is the
skilled application of muscle energy, strain/counter strain, myofascial release, manual trigger point release and
manual therapy techniques designed to improve or normalize movement patterns through the reduction of soft tissue
pain and restrictions. These can be interactive with the patient participating or can be with the patient relaxing and
letting the practitioner move the body tissues. Indications include muscle spasm around a joint, trigger points,
adhesions, and neural compression. Mobilization should be accompanied by active therapy.
(a). Time to Produce Effect: Two to three weeks.
(b). Frequency: Two to three times per week.
(c). Optimum Duration: Four to six weeks.
(d). Maximum Duration: Six weeks.
xi.
Superficial Heat and Cold Therapy is a generally accepted treatment. Superficial heat and cold
therapies are thermal agents applied in various manners that lower or raise the body tissue temperature for the
reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise. It may be used acutely
with compression and elevation. Indications include acute pain, edema and hemorrhage, need to increase pain
threshold, reduce muscle spasm and promote stretching/flexibility. Includes portable cryotherapy units, and
application of heat just above the surface of the skin at acupuncture points.
(a). Time to Produce Effect: Immediate.
(b). Frequency: Two to five times per week.
(c). Optimum Duration: Three weeks as primary, or up to two months if used intermittently as an adjunct
to other therapeutic procedures.
(d). Maximum Duration: Two months.
xii.
Transcutaneous Electrical Nerve Stimulation (TENS) is a generally accepted treatment. TENS should
include at least one instructional session for proper application and use. Indications include muscle spasm, atrophy,
and decreased circulation and pain control. Minimal TENS unit parameters should include pulse rate, pulse width
and amplitude modulation. Consistent, measurable functional improvement must be documented prior to the
purchase of a home unit.
(a). Time to Produce Effect: Immediate.
(b). Frequency: Variable.
(c). Optimum Duration: Three sessions.
(d). Maximum Duration: Three sessions. If beneficial, provide with home unit or purchase if effective.
xiii.. Ultrasound (including Phonophoresis) is an accepted treatment. Ultrasound includes ultrasound with
electrical stimulation and phonophoresis. Ultrasound uses sonic generators to deliver acoustic energy for therapeutic
thermal and/or non-thermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle
spasm, and the need to extend muscle tissue or accelerate the soft tissue healing.
(a). Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves a
dispersive electrode placement. Indications include muscle spasm, scar tissue, and pain modulation and muscle
facilitation.
(b). Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain
through the use of sonic generators. These topical medications include, but are not limited to, steroidal antiinflammatory and anesthetics.
(i). Time to Produce Effect: 6 to 15 treatments.
(ii). Frequency: Three times per week.
(iii). Optimum Duration: Four to eight weeks.
(iv). Maximum Duration: Two months.
15. Vocational Rehabilitation is a generally accepted intervention. Initiation of vocational rehabilitation requires
adequate evaluation of patients for quantification of highest functional level, motivation and achievement of
maximum medical improvement. Vocational rehabilitation may be as simple as returning to the original job or as
complicated as being retrained for a new occupation.
a. It may also be beneficial for full vocational rehabilitation to be started before MMI if it is evident that the
injured worker will be unable to return to his/her previous occupation. A positive goal and direction may aid the
patient in decreasing stress and depression, and promote optimum rehabilitation.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1850 (June 2011).
§2327. Therapeutic ProceduresOperative
A. All operative interventions must be based upon positive correlation of clinical findings, clinical course and
diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive
identification of pathologic condition(s). It is imperative to rule out non-physiologic modifiers of pain presentation
or non-operative conditions mimicking operative conditions (e.g., peripheral neuropathy, myofascial pain,
scleratogenous or sympathetically mediated pain syndromes, psychological), prior to consideration of elective
surgical intervention.
B. In addition, operative treatment is indicated when the natural history of surgically treated lesions is better than
the natural history for non-operatively treated lesions. All patients being considered for surgical intervention should
first undergo a comprehensive neuro-musculoskeletal examination to identify mechanical pain generators that may
respond to non-surgical techniques or may be refractory to surgical intervention.
C. Structured rehabilitation interventions should be strongly considered post-operative in any patient not making
expected functional progress within three weeks post-operative.
D. Post-operative therapy will frequently require a repeat of the therapy provided pre-operatively. Refer to
Therapeutic Procedures, Non-operative, and consider the first post-operative visit as visit number one, for the time
frame parameters provided.
E. Return-to-work restrictions should be specific according to the recommendation in Therapeutic
ProceduresNon-Operative.
1.
Shoulder Replacement (Arthroplasty)
a. Description/Definition. Prosthetic replacement of the articulating surfaces of the shoulder joint. There are
three types of procedures commonly performed. The total shoulder component in which the glenoid and humeral
head are replaced anatomically. The hemiarthroplasty which involves replacement of the humeral head only. The
reverse arthroplasty where the head of the humerus is replaced by a prosthesis forming a socket and the glenoid is
replaced with a ball prosthesis.
b. Occupational Relationship. Usually from post-traumatic arthritis, or from trauma resulting in severe
humeral head fractures.
c.
Specific Physical Exam Findings. Stiff, painful shoulder with limited function.
d. Diagnostic Testing Procedures: Radiographs or CTs demonstrating humeral head fracture. CTs or
diagnostic arthroscopy to explore the status of rotator cuff and associated muscles and tendons, the presence of
arthritis or subluxation, or superior migration of the humeral head. For revision procedures, a non-MRI
arthrography or sonogram may be important to better visualize associated pathology.
e. Surgical Indications. The decision of whether a patient receives a total arthroplasty or a hemiarthroplasty
depends on the surgeon’s discretion. Factors to consider are the presence of glenoid erosions, humeral head
subluxation and rotator cuff strength. There is good evidence that total arthroplasties compared to hemiarthroplasties results in improved function in primary osteoarthritis of the shoulder, and relief of pain two years postoperatively. Longer-term results are unknown.
i.
Hemiarthroplasty may utilize a long stem humeral head replacement or a resurfacing device. It may
also be performed for humeral head fractures. It has been used for severe arthritis unresponsive to other treatments;
however, there is some evidence that total shoulder arthroplasty may yield a better functional outcome. In younger
active patients the eventual wear on the glenoid cartilage may cause decreased function over time. Total arthroplasty
may therefore be preferred in many cases. Partial humeral head prosthesis may be useful in some cases. Cementless
surface humeral head replacement may be indicated in young patients with glenohumeral arthritis and retained
glenoid cartilage.
ii.
Total shoulder arthroplasty is usually performed in cases of severe arthritis when all reasonable
conservative measures have been exhausted without sufficient return to activities of daily living. Arthroscopic
surgery may be considered in selected patients with a milder degree of arthritis. Arthroscopic SLAP repair is usually
not recommended in cases of severe arthritis. The rotator cuff should generally be intact or repairable.
iii.
Reverse arthroplasty is generally considered a salvage procedure for patients over 70 with severe
osteoarthritis, massive rotator cuff tears and pseudo paralysis with integrity of the deltoid. Complications rates may
be in the vicinity of 10 percent of patients within the first year following surgery. The long-term success of the
prosthesis is not known at this time.
iv.
Reverse prosthesis may also be the treatment for failed hemiarthroplasty with extensive cuff tears
and/or instability. Most literature confirms that the complication rate is higher and the success rate lower when
reverse arthroplasty is performed on a previously operated joint, however, many patients demonstrate good
improvement with elevation, but not necessarily rotation. Bone loss may increase the complication rate.
v.
Procedural complications may include humeral head subluxation or dislocation, humeral and/or
glenoid loosening, rotator cuff tear, fractures, stiffness, painful glenoid erosion, transient nerve palsies, heterotopic
ossification, bone loss, and component mal-positioning.
vi.
Revision surgery may be performed by an orthopedic surgeon in cases with chronic pain and stiffness,
painful glenoid erosion, or difficulty with activities of daily living. Prior authorization is required and a second
opinion by a surgeon with special expertise in shoulder surgery should usually be performed. In the case of a total
failure of the prosthesis, arthrodesis is the salvage procedure.
f.
Operative Treatment: Prosthetic replacement of the articular surfaces of the shoulder.
g.
Post-operative Treatment:
i.
Individualized rehabilitation program based on communication between the surgeon and the therapist.
Timing of passive motion and active rehabilitation is dependent on the type of procedures performed.
(a). Pool exercise initially under therapists or surgeon’s direction then progressed to independent pool
program.
(b). Progression to a home exercise is essential. Therapy should continue for at least 10 weeks with
transition to home exercises at the beginning of each new phase of therapy.
(c). Gradual resistive exercise from 3 to 12 months, with gradual return to full activity at 6 to 12 months.
(i). Time frames for therapy (excluding pool therapy).
(ii). Optimum: 12 to 24 sessions.
(iii). Maximum: 36 sessions. If functional gains are being achieved additional visits may be authorized
for the patient to achieve their functional goal.
ii.
Reverse arthroplasty patients may have a more rapid rehabilitation in some cases. Per the
recommendation of the surgeon the following therapies may take place: Sling use for the first three weeks, ADLs at
three to six weeks, and then gentle strengthening.
iii.
Should progress plateau the provider should reevaluate the patient's condition and make appropriate
adjustments to the treatment plan. Other therapies may be employed in individual cases.
iv.
Gradual return to full activity can occur between 6 to 12 months, depending on the procedure.
v.
Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
2. Oats Procedure Osteoarticular allograft transplantation is a procedure which places a plug of cadaveric bone
tissue into a chondral defect at the articular surface of an injured bone. Its use has been described in case reports in
the treatment of recurrent shoulder instability when large humeral head defects (Hill-Sachs lesions) are thought to be
responsible for repeated episodes of subluxation. At this time, there is limited information concerning its
effectiveness and appropriate application. For this reason, it requires prior authorization as an isolated procedure
with a second opinion by a surgeon with special expertise in shoulder surgery. The procedure may be used for
isolated chondral/bony deficits involving the humeral head, including avascular necrosis. Partial humeral head
prosthesis may be useful in some cases. (Refer to Hemi-arthroplasty)
3.
Arthrodesis
a.
Description/Definition:
i.
b.
Fusion of the shoulder. Used as a salvage procedure.
Occupational Relationship:
i.
c.
Secondary to severe trauma and failure of other procedures.
Specific Physical Exam Findings:
i.
d.
Shoulder function is minimal and is usually associated with severe rotator cuff pathology.
Diagnostic Testing Procedures:
i.
e.
See Specific Diagnostic sections.
Surgical Indications:
i.
f.
Inability to perform activities of daily living, failed previous procedures.
Operative Treatment:
i.
Fusion.
g. Post-operative Treatment. An individualized rehabilitation program based upon communication between
the surgeon and the therapist. Therapy may begin 6 weeks to 3 months depending on recovery. Occupational therapy
is critical to improve function in activities of daily living. Assistive devices may be necessary.
i.
Time frames for therapy (excluding pool therapy).
ii.
Optimum: 12 to 24 sessions.
iii.
Maximum: 36 sessions. If functional gains are being achieved additional visits may be authorized for
the patient to achieve their functional goal.
4.
Manipulation Under Anesthesia (Refer to Adhesive Capsulitis/Frozen Shoulder Disorder)
5.
Hardware Removal
a.
i.
b.
Description/Definition:
Surgical removal of internal or external fixation device, commonly related to fracture repairs.
Occupational Relationship:
i.
Following healing of a post-traumatic injury that required fixation or reconstruction using
instrumentation.
c.
i.
d.
i.
e.
Specific Physical Exam Findings:
Local pain to palpation, swelling, erythema.
Diagnostic Testing Procedures:
Radiographs, tomography, CT scan, MRI.
Non-operative Treatment:
i.
Active and/or passive therapy for local modalities, activity modification. Nonsteroidal AntiInflammatory Drugs (NSAIDs).
f.
Surgical Indications:
i.
g.
Persistent local pain, irritation around hardware.
Operative Treatment:
i.
Removal of instrumentation may be accompanied by scar release/resection, capsular release, and/or
manipulation. Some instrumentation may be removed in the course of standard treatment without local irritation.
h.
Post-operative Treatment:
i.
Include an individualized rehabilitation program based upon communication between the surgeon and
the therapist.
ii.
Early rehabilitation interventions are recommended to maintain range-of-motion and progressive
strengthening.
(a). Frequency – Three to five times per week for the first two weeks, three times per week for the
following two weeks, then one to two times per week.
(b). Optimum Duration for six to eight weeks with progression to home exercise and or pool therapy.
(c). Maximum Duration – 12 weeks. Occasional follow-up visits may be justified to reinforce exercise
patterns, or to reach final functional goals if the therapy to date has demonstrated objective functional gains.
(d). Return to work and restrictions after surgery may be made by an experienced primary occupational
medicine physician in consultation with the surgeon or by the surgeon.
5. Human Bone Morphogenetic Protein (RhBMP) is a member of a family of proteins which are involved in the
growth, remodeling, and regeneration of bone tissue. It has become available as a recombinant biomaterial with
osteo-inductive potential for application in long bone fracture non-union and other situations in which the promotion
of bone formation is desired. In the treatment of non-union of fractures of the humerus and clavicle, no controlled
clinical trials have been conducted as of this date, though small case series have resulted in union of some fractures.
Ectopic ossification into adjacent muscle has been reported to restrict motion in periarticular fractures. Due to lack
of information on the incidence of complications and overall success rate, its use requires prior authorization. It
should be used principally for non-union of fractures that have not healed with conventional surgical management or
peri-prosthetic fractures.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1860 (June 2011).